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U S E

T H I S

O N L I N E

O  R D E R  I  N G

C O N V E N I E N C E

 

 

 

          

We value your online contact lens purchasing experience. We assure you of accuracy and confidentiality in your online contact lens purchasing.  We're committed to
the best possible care for your eyes by ensuring pre-authorization from your
preferred eye doctor.  A copy of your order will be e-mailed to you. Your
eye care practitioner will receive a copy for approval or correction.
Please contact their office if you have any questions.

Credit Card Information is required to order through this site

Required fields are marked with an *

 

Patient Information
     
 
Patient Name

First  *   

Last  *    

 

Address *

 

 

 
City *

 
State *
       Zip Code *
 
Phone number
 
Email Address *
  Confirm Email Address *
  Shipping
Method
       
Is the Shipping Address
t
If Not,
enter Shipping Address below
 

Address

 

 

 
City
 
State
       Zip Code
     
Practitioner Information
  Practice Name *
  Doctor's Name
  Phone Number *
  Email Address
 

 

Authorization information -- if provided by your EyeCare Practitioner

Lens Description

Soft lens
Gas Perm

 
Right Eye (OD)
Left Eye (OS)
Brand name
Base Curve
Diameter
Power
Color
Quantity
Additional
GP Information
   
Special Request
   
Credit Card Information
 

Card Type *

Name on Card *

Expiration Date (mm/yyyy) *

Card Number *

Security Code * If on your card

Is the Credit Card Billing Address
the same as in Patient Information section?
 
If not,
enter Credit Card Billing Address below
 

Address *

 

 

 
City *
 
State *
       Zip Code *
   
 
Fraud Protection Warning:
Processing of your order may be delayed if the name and address provided for this
credit card do not match the billing address of the card.
   
This Contact Lens Order is subject to the approval of your EyeCare Practitioner. 
Pricing and Payment are handled by their Accounting Department. 
If you have any questions contact their office.