contact_orders

Contact Lenses Order Form

You may use this form to order Contact Lenses if you are a patient of The Eye and Vision Center.

We will send an email confirmation when we receive your order. After we verify your prescription and applicable insurance, we will contact you by phone to arrange payment as specified below.

Fields marked with an * are required.

Patient Information

First Name *

Last Name *

Date of Birth *

1. Insurance to be Used *

(Please select "None" if not applicable to this order)

2. Choose your Contacts *

My contacts aren't listed. Please contact me.

3. # of Months Supply *

(Not all brands are available in each choice and supply may depend on your prescription and prescribed replacement schedule.)

3 Mo 6 Mo 9 Mo 12 Mo

4. Ship to: *

The Eye and Vision Center (for pickup) Shipping Address:

Name

Address

City

State

Zip

5. Preferred Payment Method: *

(We will contact you by phone to arrange payment before finalizing this order.)

Credit Card Check Cash

6. Contact Info: *

Daytime Phone # *

Email *

Re-Enter Email *

Special Instructions