Contact Lens Order Form

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To help easily and accurately order contacts with us

Email *

What is the best phone number to reach you?

Are you ordering the lenses for yourself or someone else? *

What is the full name of the person the contacts are for? *

Are you ordering for the Right eye, Left eye, or Both eyes *

Please tell us about your contacts prescription *

Bala Eye has my updated Rx

The doctor gave me options - I will write my decision in the next section

I am not sure - I need to talk to someone

I'm not a patient - I will email my current Rx to eyecare@balaeye.com

If there is any question about your prescription, please write as much as you can below for the Right and Left eye.

If we prescribed your contacts this is likely unnecessary.

Which supply would you like? *

Year supply

6 month supply

1 month supply

Other:

Should we ship to you or pickup at the office? *

Ship to me (free for Daily Disposable lenses if ordering 6-12 months)

Pickup at the office

Shipping Address: (only required if shipping)

Are you using VSP vision benefits to pay some portion of these lenses? *

How would you like to pay?

Note: lenses are ordered when payment is received.

Email me the invoice to pay

Text me the invoice to pay

Call me to take payment

If your card is on file, do you authorize payment? *

Yes (We will charge the card and send receipt)

No (Please send an invoice first to review)

We welcome any suggestions or feedback to help us improve.

Send me a copy of my responses.

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