Order Contact Lenses

Patient Name

Date of Birth

Day Phone #

Evening Phone #

Email

Contact lenses are typically sold in boxes of the following: 1, 3, 6, or 12 month supplies. Please indicate the supply quantity and the number of boxes.

Supply Quantity:

Number of Boxes:

1 month supply
3 month supply
6 month supply
12 month supply

    1 2 3 4 5 6

Delivery Options:
We charge an additional $5.00 if you want your order mailed to your home. If contacts are to be mailed please confirm your address in the comments field below. (If you order a year's supply we will pay the shipping for you.)

Mail order to my home

Pick up order at the office

Additional Comments/Questions:
(Contact lens brand/type, ordering more than 6 boxes, address if having the order mailed, any other comments or questions for the doctor, etc.)

Thank you, we will contact you either by email to confirm your order or by phone if we have any questions. Ask about our Annual Contact Lens Packages where you can save money on your contact lenses.