CONTACT LENS ONLINE ORDER FORM

If you would like to place an order for contact lenses, please complete the following form. We will be happy to mail them to you or you can pick them up at our office. One of our staff will call you to confirm your order.

We accept orders from both clients and non-clients. If you are not currently a client at our office, we will need to get your prescription information from you or schedule an appointment to determine the correct lenses for your vision needs.

All fields marked with an asterisk (*) are required.

**Shipping costs: ~~If you are purchasing a six-month (4 boxes) or more supply of contact lenses, there is no shipping charge. For orders less than 6 months/4 boxes, a $6.00 shipping charge will be added to the order.~~

FREE shipping on contact lenses until the end of May.

EXCEPTIONS:
~~Oasys bi-weekly lenses require an order for one year (24 pack or 8 boxes) for free shipping. Otherwise a $6.00 fee will apply.~~

~~CIBA lenses – free shipping applies to orders greater than one box. No P.O. boxes allowed (for these lenses).~~

No exceptions during the COVID-19 pandemic. All contact lenses will be shipped for free.

Contact Lens online order form

I am: *

a current client

NOT a current client

If you are not currently a client, we will need to get a copy of your prescription information before we can order your lenses. Please use the online appointment form to schedule an appointment with us or give us a call with your information.

Personal Information

Title

Name *

First Name

last name *

Last Name

Date of birth *

Daytime phone *

Email Address *

(Your email address is for confirmation purposes only. It will not be shared with any third party.)

Order Details

When was your last eye exam?

(If you are unsure of the exact day, please use '1'; if you are unsure of the month, use 'January'.)

Type of lenses required? * Type of lenses required?

eye *

Right eye

Left eye

Quantity**

1 year

6 months

3 months

OR number of boxes

(**Shipping costs: If you are purchasing a six-month (4 boxes) or more supply of contact lenses, there is no shipping charge. For orders less than 6 months/4 boxes, a $6.00 shipping charge will be added to the order. See exceptions above.)

Preferred delivery: *

Anything else we should know?

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Clearer vision for a better life.

CONTACT LENS ONLINE ORDER FORM

Personal Information

Order Details