ORDER CONTACTS

FOR EXISTING PATIENTS ONLY
Please use the following form to order your contact lenses.
First Name*
Last Name*
Date of Birth (mm/dd/yyyy)*
Where Was Your Last Exam?*
 Roscoe Southport
Street Address*
City*
State*
Zip Code*
Phone*
Email*
I’m Ordering Contact Lenses for My:*

How Would You Like to Receive Your Contacts?*
 Please ship to my address above (Shipping Fee is $8.00 and will take 5-7 business days. This will be added to your order) Email me when my contacts are ready. Call me when my contacts are ready.
Where Would Your Like to Pick Up Your Contacts? - Only check if picking up contacts
 Roscoe Southport
PLEASE NOTE: Someone from our office will call you to collect payment via phone before your order is placed.
Questions or Comments:

* Required