Order Contact Lenses

ORDER CONTACT LENSES
We offer this reorder service for patients that we have seen at our office. Please indicate the number of boxes (or conventional wear lenses) requested for each eye. If you want us to mail the lenses to you, please indicate your current mailing address. There is a $6.00 charge for mailing – four boxes or more are mailed at no charge.
Name
Address
City
State
Zip
Phone
Alternate Phone
Email

Contacts Needed
Right Eye	# of Boxes
Left Eye	# of Boxes

Pick Up at Office
Mail to Me

Credit Card Information
Card Type
Card Number
Expiration Date
V-Code (last 3 digits under the signature bar on back of card)

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