Patients of our office can use this form to order more contact lenses online. If you would like a different type of contact lens from your last purchase, please contact us to discuss your options.

For your eye health and comfort, you must have had a full eye examination including a contact lens assessment within the past two (2) years to use this form.

Ordering Instructions

  1. Complete the form below
  2. Our office will contact you when your order is ready
  3. You can pick up your order and make payment during office hours

Your Full Name



How should we contact you when your order is ready?

Your phone number
Your e-mail address

How many pairs of lenses do you want?

For regular contacts
For dailies (daily disposable) contacts

Add solution to your order?

Include solution
Check this box to include a discounted supply of our recommended solution to your purchase.

Question or comments about your order? (optional)

For your privacy, please do not send sensitive medical
or financial information using this form.

What is

(This helps us reduce spam)

Thank you!