Contact Lens Order Form

Thank you for your interest in purchasing your contact lenses from our office.
We take great care and pride in all the services and products we provide, and appreciate your loyalty to our clinic.

In order to process your order, please answer the following questions:

First Name

Last Name

Date of Birth ( D/M/Y )

Telephone

E-Mail

Lenses

6 Month Supply
12 Month Supply *

Other Amount

* Purchase a one year supply of contact lenses and receive a significant savings
on your contact lenses and the solutions that we stock.

* Have you purchased your contact lenses from our office before?

Yes
No

* Please be advised that you must have had an eye health exam within the last 24 months
in order to purchase contact lenses.

Date of last eye health exam ( D/M/Y )

* If eye exam was not done at our office, please provide us with the name of the doctor and the location.

Doctor's Name

Location

Additional commetns or questions:

Thank you for your interest in purchasing your contact lenses from our office.

You can now order your contact lenses online!

Contact Lens Order Form

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