Contact Lenses Order Form

You may use this form to order Contact Lenses if you are a patient of The Eye and Vision Center.

We will send an email confirmation when we receive your order. After we verify your prescription and applicable insurance, we will contact you by phone to arrange payment as specified below.

Fields marked with an * are required.

Patient Information

1. Insurance to be Used *

(Please select "None" if not applicable to this order)

2. Choose your Contacts *

ACUVUE
Bausch + Lomb
Alcon
CooperVision
Metro Optics

3. # of Months Supply *

(Not all brands are available in each choice and supply may depend on your prescription and prescribed replacement schedule.)

4. Ship to: *

5. Preferred Payment Method: *

(We will contact you by phone to arrange payment before finalizing this order.)

6. Contact Info: *