Contact Lens Order Form

Please use the form below to submit your contact lens order request. We stronly suggest that you read all of the order information carefully before submitting your order.

Name: (Required)
Address:
City:
State:
Zip:
Daytime Phone: (Required)
Email: (Required)
Date of Birth: (Required)	/ / Male Female
Order Information
Indicate Order Quantity:
Number of Boxes for Left Eye:
Number of Boxes for Right Eye:
Will we be using your Vision Plan for the ordering of your lenses?	(Yes or No)
Shipping Information
Would you like us to ship them to your home for a $6.00 shipping fee? If yes, please note your shipping address is required.	(Yes or No)
Important Information Regarding Your Order
Your lenses will be available for pick-up in 7-10 business days. You must pay for the lenses at the time of order. We accept credit card information over the phone. Please be advised if there are any questions about your order our representative will contact you at the contact number provided on this form. If your prescription is more than a year old we will be unable to fill it at this time. You must schedule an appointment to see one of our eye care professionals. Contact lenses will not be held for more than 30 days from the date of receipt. Please be advised that you are submitting this request over the internet. Do not include sensitive medical information in your order request as we cannot guarantee it will not be seen by toher parties.
Additional Information:
We will contact you to confirm your order.