Contact Lens Order Form

It is necessary to have a valid contact lens prescription on file at our office.
Indicates required information.

Step 1: Contact Info

Step 2: Product Info

Quantity (in number of boxes):

Step 3: Comments


Step 4: Payment Options

Once your online request has been received we will send an invoice to the email address you entered above. You will be able to confirm your delivery address and select one of the following payment options at that time. If you have insurance benefits and would like to have them billed, please indicate this in the comments box above.

Shipping charges may apply. Annual supplies ship at no charge. Shipping fees are not covered by insurance.
PayPal VISA MC Amex Disc Debit

Step 5: Finalize


We value your privacy. Your e-mail address will not be given/sold to third parties and will only be used to respond to this inquiry and future correspondences.