Online Contact Lens Order

 

Please Complete Patient Information Form Below

First Name:
Middle Name:
Last Name:
Mailing Address: 
City:
State:  
Zip Code:
Daytime Telephone:
E-Mail Address:
Approximate date of last eye examination              19 or 200
No.of Boxes or Lenses:  Right Eye     Quantity
No.of Boxes or Lenses:   Left Eye        Quantity 

Additional Comments Below


 
If it has been more than two years since your last eye examination or one year since your last corneal check, please call 509-456-8121 to schedule an appointment with your eye doctor. If you do not receive an order confirmation by email or telephone within 48 hours, please telephone the
contact lens department at 509-624-1516
 
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