Order Contact Lenses

Please complete the following to help expedite your order:

Name:

First Last

Date of Birth:

Your Contact Lens Brand

Upload Photos of Your Contact Lens Boxes HERE instead of Completing the Form but please specify the number of boxes you are ordering below

Max. file size: 31 MB.

Right Eye:

Left Eye:

Your Contact Lens Power

Right Eye:

Left Eye:

Number of Boxes and Specify box type (30 pk, 90 pk, 6 pk, 12 pk, 24 pk)

Right Eye (specify number per pack):

30 per pack (for daily lenses), 90 per pack (for daily lenses), 6 or 12 per pack (for bi-weekly/monthly lenses)

Left Eye (specify number per pack):

30 per pack (for daily lenses), 90 per pack (for daily lenses), 6 or 12 per pack (for bi-weekly/monthly lenses)

Do you need us to check your insurance coverage for the cost of the contact lenses?

Yes

If yes, what is the name of your insurance?

We will be contacting you by email to calculate the cost of your lenses from the information above. Please provide the best email and phone number to contact you and any questions below:

Phone

Questions

Once you approve the information about the cost of your lenses and confirm the number of boxes you need, we will contact you to acquire payment and proceed with the order. All orders will take up to 15-30 business days. Thank you!

Your Contact Lens Brand

Your Contact Lens Power

Number of Boxes and Specify box type (30 pk, 90 pk, 6 pk, 12 pk, 24 pk)

Jennifer Ong, O.D.