Contact Lenses

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

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