Order Contact Lenses

Title
First Name*
Last Name*
Phone*
(### - ### - ####)
Email*
Type of lenses required*
Please complete the name of the contact lenses you are ordering. Our office will confirm with our records to ensure the proper lenses are ordered!
Eyes*
- Left
- Right
- Both
Quantity
- 1 year supply
- 6 month supply
- 3 month supply (available for daily disposable only)
Address for direct shipping **please complete this field if you would like your contact lenses shipped to you. Shipping is currently NO CHARGE for all orders!
Message / Comments; please note our office will contact you via phone to arrange payment or direct billing for insurance, if applicable.
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