Order Contact Lenses

To order contact lenses, please call our office (view phone numbers)
or complete the following Contact Lens Order Form.
A contact lens specialist will contact you to confirm your order.

(Please note, in order to protect the health of your eyes, a current “non-expired”
contact lens prescription is required to purchase contact lenses.)

First & Last Name: *
E-mail Address: *
Phone Number: *

Number of boxes per eye:

Left: *
Right: *

I am a patient at: *
Date of Birth:
Why do we ask this?
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Delivery Option: *
Shipping Address:
Additional Information:
Security Verification:*
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Please do not use this form to transmit confidential information.

* Required