Rainbow Optics Contact Lens Order Request
Filling out this form will submit a request to Rainbow Optics to order contact lenses.

Within one business day of receiving your request, we will verify your prescription with your doctor, call you to review and confirm your order, and provide you with an estimate of when we expect your contacts to arrive.

If you need your order placed right away, please call us directly:
Campus (E. 13th Ave.) - 541.343.3333
Westside (18th & Chambers) - 541.343.5555
Sheldon (Willakenzie Rd.) - 541.484.9999

We are open:
Monday - Friday: 9:00am - 5:30pm
Saturday: 9:00am - 5:00pm
Sunday: Closed

We are closed the following holidays: New Year's Day, Memorial Day, 4th of July, Labor Day, Thanksgiving Day, Christmas Eve and Christmas Day.

First Name
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
How many boxes would you like to order? *Please specify quantity for right eye and for left eye.*
Example: Please order 2 boxes for right eye, 1 box for left eye.
Your answer
Phone number you would like us to call to confirm your order.
We will not be able to complete your order request until we speak with you.
Your answer
Where would you like to pick up your order?
Please select from the drop down menu below. If you prefer to have your contact lenses shipped, please confirm the address you'd like them sent to when we call you. UPS ground shipping fee $9.00.
Name of prescribing doctor:
Please select from the drop down list
Would you like us to bill your insurance?
If Yes, please provide name of your vision insurance company.
Your answer
Additional Comments
If you had your exam with a practice other than Rainbow Optics, please provide the doctor's name and fax or phone number so we can contact them to confirm your prescription.
Your answer
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