Please do not disclose any medical information in this form. Our contact lens specialist will call you if we have any questions. All orders must be paid prior to ordering and must have a current prescription. All orders will be placed on the next business day. Name * First Name Last Name Name of your required Contact Lenses * Number of boxes required * Please add any notes Supply * Annual Monthly/Daily Email * Phone Number * (###) ### #### Use Insurance (if available) * Yes No Delivery * I'll pick up my order at Vision Care Associates, P.C. Please ship directly (may incur shipping fee) Thank you!
