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.
1. Insurance to be Used *
(Please select "None" if not applicable to this order)
2. Choose your Contacts *
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
6. Contact Info: *