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Contact Lens Replacement Order Form

First Name:
Last Name:
Email Address:
Street Address:
City:
State:
Zip Code:
Phone Number:
Date of Birth (mm/dd/yyyy):
Order Information
	Number of Boxes
Right Eye:
Left Eye:
Delivery Information
Call me when my contacts are ready. I will pick them up Please mail my contacts UPS and charge me and additional $10. Please overnight my lenses so I receive them ASAP and charge me $20. (Rigid gas permeable and made-to-order lenses must be manufactured prior to over nighting which can take 2 to 14 days on average.)
Payment Information If you are requesting we ship the lenses to you, we need payment prior to mailing. We accept MasterCard, VISA, and Discover. Please choose one of the following options:
I will call your office and give you my credit card information. I will provide payment when I pick up the lenses in the office.

St.Vincent Health Medical Services