If you are a current patient, we will have your contact lens prescription in our office and you may order additional contact lenses using this form. We will call you when they have arrived, and you may either come by to pick them up or we may mail them to you.

All contact lens wearers need to see their eye doctor on an annual basis to maintain good eye health and a valid contact lens prescription.

Orders will be available for pick up at our office in most cases within 5 working days.

Direct shipping is also available at an additional charge. If you desire this option, indicate so on the form below.

Today's Date*:

First Name*:

Last Name*:

Address 1:

Home Phone*:

City:

Email Address*:

Additional Questions, Comments and Instructions:

Address 2:

State:

Zip:

Left Eye Lenses:

Right Eye Lenses:

Please Select One 1 Box 2 Boxes 3 Boxes 4 Boxes Six Month Supply One Year Supply None Please Select One 1 Box 2 Boxes 3 Boxes 4 Boxes Six Month Supply One Year Supply None No Yes

** Select yes to have your order  shipped to you. There is an $9 shipping fee added to contact lens orders of less than 1 year supply. Shipping is complementary on all orders of a full years supply.

Contact Refills

Refill Information