Contact Lens Order Form
We understand that many of you are running low on your contact lens supply. As we are unclear when we will resume our patient care, please check your contact lens supply and let us know if you need contact lenses delivered to your door. At this time we are able to offer shipping of two boxes or more at no charge.
Email address *
Patient Last Name *
Your answer
Patient First Name *
Your answer
Quantity of Lenses Requested *
Your answer
Do you have VSP? *
Do you wish to use your VSP benefit for contact lenses in lieu of glasses? *
Shipping Address *
Your answer
Phone Number *
Your answer
Any additional comments?
Your answer
We will send you Square credit card transaction via email. Upon receipt of payment, your contact lenses will be ordered and shipped.
A copy of your responses will be emailed to the address you provided.
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