If you require contact lenses and would like us to contact you, please fill out the form for your lenses and we will gladly get in touch with you shortly! Contact Information Name: Phone: Email: Contact Lens Brand Right eye: I’m not sure / Not listedDropdownClariti 1-dayClariti 1-day toricClariti 1-day multifocalBiofinity 1-monthBiofinity 1-month toricProclear multifocal 1-monthProclear toric multifocal 1-monthAcuvue 1-day moistAcuvue 1-day moist for astigmatismAcuvue 1-day moist multifocalAcuvue 1-day oasys hydraluxeAcuvue 1-day oasys hydraluxe for astigmatismAcuvue oasys 2-weekAcuvue oasys 2-week for astigmatismAcuvue vita 1-monthDailies aquacomfort plus 1-dayDailies aquacomfort plus toric 1-dayDailies total 1 (1-day)Air optix 1-monthAir optix for astigmatism 1-monthAir optix multifocal 1-monthBiotrue 1-dayBiotrue 1-day toricBiotrue 1-day multifocalUltra 1-monthUltra 1-month toric Left eye: I’m not sure / Not listedDropdownClariti 1-dayClariti 1-day toricClariti 1-day multifocalBiofinity 1-monthBiofinity 1-month toricProclear multifocal 1-monthProclear toric multifocal 1-monthAcuvue 1-day moistAcuvue 1-day moist for astigmatismAcuvue 1-day moist multifocalAcuvue 1-day oasys hydraluxeAcuvue 1-day oasys hydraluxe for astigmatismAcuvue oasys 2-weekAcuvue oasys 2-week for astigmatismAcuvue vita 1-monthDailies aquacomfort plus 1-dayDailies aquacomfort plus toric 1-dayDailies total 1 (1-day)Air optix 1-monthAir optix for astigmatism 1-monthAir optix multifocal 1-monthBiotrue 1-dayBiotrue 1-day toricBiotrue 1-day multifocalUltra 1-monthUltra 1-month toric Prescription: My latest prescription on fileI will e-mail my prescription for verification How many months of lenses would you like to order per eye? (Monthly’s come in 6-packs, dailies come in 90-day supply): Right eye 3 Months6 Months9 Months12 Months Left eye 3 Months6 Months9 Months12 Months Any notes you’d like us to know? (i.e how many months of lenses you would like to order per eye, questions regarding rebate offers): How would you like to be contacted regarding your order? PhoneEmailText What does 5+5=? Please leave this field empty.
