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Home
About Us
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CarlinVision Blog
Services
Lasik
Cataracts
Eyelid Surgery
Retina
Dimple Modi, M.D., M.P.H.
Diabetic Retinopathy and Treatment
Macular Degeneration
Floaters and Flashes
Dry Eyes
Optical Boutique
Contacts
Re-order Contacts
Re-order Contacts
Home
Patient Forms
Re-order Contacts
Re-order Contacts
DJ Helms
2017-06-01T23:19:39-04:00
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
*
Month
Day
Year
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.
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
*
Visa
MasterCard
Discover
American Express
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
Alabama
Alaska
American Samoa
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Arkansas
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Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
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