Contact Lens Replacement Order Form First Name: Last Name: Email Address: Street Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Other Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: 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 an 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.