Contacts & Fittings

You must have had a complete eye exam within the past twelve months to order contact lenses.

Please complete all required fields below. Orders received after 2 pm will be placed the following business day.

Please check the required fields

1. Full Name  
2. Street  
3. City  
4. State  
5. Zip  
6. Preferred Phone Number  
7. Alt Phone  
8. Email  
9. Preferred Contact  
   Email
   Phone
   
10. Quantity  
    Choose Your Quantity 3 Month Supply 6 Month Supply 12 Month Supply Yearly Lenses
11. Which Eye ?  
    Select Eye Left Eye Right Eye Both
12. Comments/Questions?  
13. Mail or Pickup?  
    Mail Them To Me ($7 for less than 1 yr supply)
    I'll Pick Them Up
    
14. Security Code: *
    Reload Image
    
15.  
    Privacy Statement: The information which you give in completing this form will be forwarded to the designated party for its use and will not be used by Real Pages for any other purpose or provided by us to any other parties.