(*indicates mandatory fields)
Right Eye* boxes
Left Eye* boxes
Contact Information
First Name*
Last Name*
Email*
Street Address*
City*
State* AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
ZIP*
Phone Number*
Date of Birth (mm/dd/yy)*
Delivery Information
Call me when my contacts are ready. I will pick them up. Please mail my contacts UPS and charge me an additional $10. Please overnight my lenses so I receive them ASAP and charge me $20. (Rigid gas permeable and made-to-order lenses must be manufactured prior to over nighting which can take 2 to 14 days on average.)
Payment Information
If you are requesting we ship the lenses to you, we need payment prior to mailing. We accept Mastercard, Visa and Discover. Please choose one of the following options:
I will call your office and give you my credit card information. I will provide payment when I pick up the lenses in the office.