Please fill out the information below to place an order for contacts. Please note shipping in general takes 5-7 business days.

Name

First Name

Last Name

Email

Phone

(###)

###

####

How would you like to receive your contacts?

Deliver to you

Pick up in office

Have you previously ordered contacts with our practice?

Yes

No

If we are mailing contact lenses to you, please provide the address we should send to:

How would you like to pay?

Rx, Lens Type, and Quantity

Please indicate in the box below your current contact prescription, what brand of lens you are wearing, and how many months' supply you would like to order. This information can be found on your current contact lens boxes.

Contact Lens Order Form