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: -SELECT- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip: Daytime Phone: (Required) Email: (Required)   Date of Birth: (Required) 1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 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.