If you would like to place an order for contact lenses, please complete the following form. We will be happy to mail them to you or you can pick them up at our office. One of our staff will call you to confirm you order.

All the fields followed by a * are mandatory.

First name*: 
Last name*:
Date of birth* (YYYY/MM/DD): / /
Day time telephone*: 
(for confirmation email only, will not be given to a third party)
Type of lenses required*:  Name of product:  
  Right Eye Left Eye
  Quantity: 1 year 6 months Refill my last order
Would you be interested in being kept informed of clinic promotions, offers or updates?
Yes No