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Blade Free Lasik
The Safest Option!
Blade Free Lasik experience provides an unprecedented level of safety, precision and comfort! Click for more info

 

Order Contacts

Please reorder your contacts using this convenient form. We will contact you to confirm your order.

About You
Patient Name:
Last four digits of SSN:
Required for account verification
Birth Date:
Phone:
Email:
   
Contact Lenses
Lenses Needed (Quantity): Right:    Left:  
   
Insurance
  Will you be using your vision insurance to cover the cost of your contacts?
Insurance in name of:
Covered person's SSN:
   
Credit Card Info
Card Issuer:
Name on Card:
Card Number:
Expiration Date:
Security Code: What is this?
[If you prefer to pay by check, your order will be shipped upon receipt of payment.]
   
Delivery
You will pick up your new contacts.
We will ship your new contacts to the following address:
Address City/State Zip
   
Finally...
Additional comments or instructions:
Thank you for giving us the opportunity to serve you!

  

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