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Contact Lens Order Form
Name*
First*
Last*
Phone*
Email*
Date of Birth MM/DD/YYYY*
Would you like to reorder the same lenses or order the new lenses you are trialing? Please check one of the following:
Please reorder the same brand that I purchased the last time.
Please order the new lenses that Dr. Hotz or Dr. Lafleur gave me to trial at my last appointment.
How many boxes of lenses would you like? Remember, rebates and promotional pricing may apply on 1 year supply. Please check one of the following:
4 boxes: 1 year – monthly lenses or 6 months daily disposable
2 boxes: 6 month – monthly lenses or 3 months daily disposable
A different supply – see comments section below
Call me to explain any promotional pricing.
Would you like to order contact lens solution with your lens supply? Bundling saves money.
Yes! I want to save the solution’s tax! (sorry, we do not direct ship solutions).
No thanks. Not this time
Pick/Delivery Options*
I will come to the office to pick up my lenses
Please ship to my home address - Please contact me with applicable shipping fees.
Please ship to my work address - Please contact me with applicable shipping fees.
Shipping address, if different from home address*
Additional comments/Special requests/If ordering solution name preferred product*
