CONTACT LENS ORDER
If you are an established patient of our practice you can order contact lenses online. If you are not an established patient please make an appointment or contact us.
Last Name
Middle Name
First Name
Email Address
Confirm Email Address
Preferred Contact Number
Preferred Contact Method :
Phone
Email
Prescription
Please tell us what you want to order. If you want to order based on the last prescription in your file please check "use the prescription on file" if you have received several trials and prefer one over the other please right the information.
Brand
Power
Base Curve
Diameter
Right Eye
Rx on file for right eye
Left Eye
Rx on file for left eye
Comments:
We will send an e-mail to you confirming that we received your form. And will contact you when your lenses are ready for pick up. You wil be charged at the time of the pick up.