Order Contacts



Please use the form below to order your contact lenses:















Select the brand of contacts you wear in the RIGHT eye:

Select the brand of contacts you wear in the LEFT eye:

If your brand is not listed above, please indicate here:



For color contacts, please specify color you would like:




Enter your prescription information from your box (or use the radio buttons for same as last order/last trials:

RIGHT Eye (OD) Sphere:

Right Eye (OD) Cylinder (for astigmatism only):

Right Eye Axis (OD) (for astigmatism only):


LEFT Eye (OS) Sphere:

Left Eye (OS) Cylinder (for astigmatism only):

Left Eye Axis (OS) (for astigmatism only):


Order lenses from:
Same as Last Order

Trials


For gas permeable lenses enter how many lenses you want for the



For disposable lenses enter how many boxes you want for the





Where would you like your contacts shipped to:
to Patient*

to Office


Do you have Insurance? If so, please complete the following:

(VSP) Vision Service Plan

EyeMed

Social Security # (We need this to complete your order through your vision plan)


For shippment to you, we do need payment in advance please provide credit card information ($8 shipping charge for orders less than 1 year supply):

  
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