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 members will call you to confirm your order.

We accept orders from both patients and non-patients. If you are not currently a patient 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.

Contact Lens online order form

I am: *

a current patient

NOT a current patient

If you are not currently a patient, 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 --Please select-- Ms. Mrs. Mr. Dr. Rev. Please do not use a 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? * --Please select-- Acuvue Oasys Oasys for Astigmatism Acuvue 1-Day Moist 30 pack Acuvue 1-Day Moist 90 pack Acuvue 1-Day TruEye 30 pk Acuvue 1-Day TruEye 90 pk Acuvue Oasys for Presbyopia Acuvue 1-Day Moist Toric 30 pk Focus Dailies AquaComfort Plus 30 pack Focus Dailies AquaComfort Plus 90 pack Air Optix Air Optix for Astigmatism Air Optix Multifocal Other Type of lenses required?

eye *

Right eye

Left eye

Quantity**

1 year

6 months

3 months

1 month

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: * --Please select one-- Pick-up at the clinic Please mail them to me**

Anything else we should know?

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