Contact Lens Order Form
(Please note that we may have to contact you before we proceed with your order. If it has been more than 1 year since your last eye exam, we will need to book an appointment to reassess your eye health and vision, to order more contact lenses.)
Would you like to reorder the same lenses, or order the new lenses you are trying? *
Please reorder the same brand that I purchased the last time
Please order the new lenses that I am trying
I am interesed in trying a complimentary pair of new lenses
How many boxes of lenses would you like? Remember, you save $$ when you purchase a 1 year supply. *
a different supply - see comments section below
Would you like to order Contact Lens Solution with your lens supply? *
Yes! ......I like to save money.
No thanks. Not this time.
Pick up/Delivery Options *
I will come to the office to pick up my lenses
Please ship to my home address - shipping fee $15
Please ship to my office address - shipping fee $15
Shipping Address, if different from home address.
Additional Comments/Special Requests
Do Not Fill This Out