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.
Patient Last Name
Patient First Name
Quantity of Lenses Requested
Do you have VSP?
I don't know
Do you wish to use your VSP benefit for contact lenses in lieu of glasses?
Yes, use my VSP benefit for this order
No, I want to save my benefit for glasses
I don't have VSP
Any additional comments?
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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