Contact Lens Order

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Will you be using Insurance?*

YesNo
Insurance Type
We provide free shipping for a one year supply of contacts (a six month supply if you wear daily-wear)
Do you want contacts shipped to you?*

YesNo
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Brand of Contacts (optional):
Prescription

You can find your prescription on the side of your box
Right Eye
Power/Sphere
BC
DIA
Add Power (if applicable)
Cylinder Power
Axis
Left Eye
Power/Sphere
BC
DIA
Add Power (if applicable)
Cylinder Power
Axis
Supply Quantity

1 Month3 Months6 Months9 Months1 Year1 Box2 Boxes3 Boxes4 Boxes
Payment Information
Credit Card Number*
Expiration Date*
Security Code*
Preferred Contact Method

Phone CallEmailText
We will call you in advance to confirm the cost and before we charge your credit card
- 10% off annual supply
- Free direct ship on annual supply or 6 month supply for daily disposables
- There may be a rebates, up to $300, depending on your lens type
Should be Empty:

Payment Information