Contact Lens Order Form

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Place your contact lens order using this form. Flat $10 shipping fee applies. Free shipping on six month supply of single use lenses.We will send you a Square credit card transaction via email. Upon receipt of payment, your contact lenses will be ordered and shipped.

Email *

Patient Last Name *

Patient First Name *

Quantity of Lenses Requested *

Do you have VSP? *

Yes

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

N/A

Shipping Address *

Phone Number *

Any additional comments?

We will send you a 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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