Order Contacts

Name *

For whom are we ordering contact lenses?

First Name

Last Name

Phone Number *

(###)

###

####

Supply Quantity *

How much of a supply would you like?

3 months

6 months

12 months

Other (please specify in the notes section at the bottom of the form)

Shipping *

How would you like to receive your contacts?

I will pick them up at the office.

Direct ship to me $10 (included at no charge for year supply order).

Shipping Address

If you would like us to mail your contacts order, to which address should we send them?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country