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Contact Lenses Ordering Form
*For your eye health all the contact lenses ordering would require initial fitting and follow-up exams at our clinic. If you are already using contact lenses now, the fitting will be reassessed.
Please fill in the information in the form below regarding the contact lenses you would like to order.
All online orders will require a phone confirmation.
Name
*
First
Last
Phone number
*
Email
*
Your current contact lens brand:
*
Left Lens Base Curve:
*
Right Lens Base Curve:
*
Left Lens Diameter:
*
Right Lens Diameter:
*
Left Lens Power:
*
Right Lens Power:
*
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