Date

Name

First Last

Phone Number

Email

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Order Details

Please add order information for each eye, quantity and type of lens

Right Eye

Left Eye

Reorder Quantity*

6 month supply of contact lenses
12 month supply of contact lenses
a different amount of contact lenses - please specify below

Amount if other than 6 or 12 months:

Pick up delivery options:

I will come to the office to pick up
Please ship to my office address - a shipping fee may apply
Please ship to my home address - a shipping fee may apply

Shipping address if different from home address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For shipping options, we will contact you for payment information. Your contact lenses will normally arrive in 2-3 business days. If you haven't received them after 4 days please contact our office at: 905-659-3937.

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Order Details

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