Re-order Contacts - CarlinVision

Please re-order your contacts using this convenient secure form. We will contact you to confirm your order or if we have any questions.

About the Patient

Enter the patient`s name, birthdate and last four digits of the Social Security number (for account verification).

Name

First Last

Birth Date*

MM

DD

YYYY

Contact Lenses

How many boxes of lenses do you need for each eye?

Number of BOXES for LEFT Eye*

Number of BOXES for RIGHT Eye*

Will we bill your vision insurance for your new lenses?

I want CarlinVision to bill my vision insurance provider
I accept full responsibility for the cost of my lenses

Insurance

All or a part of the cost of your lenses may be covered by your vision insurance.

IMPORTANT: I understand that by submitting this order, I accept responsibility for payment of the balance not paid by my insurance provider.

Vision Insurance Provider*

Name of Insured*

Insured` Social Security Number*

Delivery & Payment

You can pick up your new lenses and pay for them at that time, or you can provide credit card info and we will ship them to you.

How should we deliver your contacts?*

I will pick up my new contacts and pay at that time
Ship my lenses to me. Payment info is below

NOTE: Shipping is free on orders of a year's supply or more. The shipping charge on smaller orders is $9.95.

Thank you! We will contact you when your new lenses are ready for pickup. Please provide your contact info below and click `Submit Order.`

Credit Card Information

You authorize us to bill your credit card for the cost of your new lenses.

Card Issuer*

Name on Card*

First Last

Credit Card Number*

Expiration Date*

CVV Number*

The three- or four-number security code. Need help?

Please enter a number from 001 to 9999.

Billing Address*

Street Address Address Line 2 City State ZIP Code

Where will we send your new lenses?*

Send to my billing address above
Send to a different address

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Contact Info

Please provide your phone and email address so that we can send you an order confirmation and contact you in case we have questions about your order.

Phone*

Email*

Enter Email Confirm Email

Last Stuff

Anything else that we need to know about your order?