Reorder Contact Lenses Patient Information Patient First Name Required Patient Last Name Required Address Required City Required State Required Zip Code Required Phone Number Email Address Confirm Email Address Shipping Method Ground 2nd Day Next Day Other - List in Special Request Box Below Is the Shipping Address the same as in Patient Information section? Yes No If Not, enter Shipping Address below Address City State Zip Code Lens Description (as shown on the package or prescription) Type Soft lens Gas Perm Right Eye (OD) Left Eye (OS) Brand Name Base Curve (BC) Diameter (Dia) Power (sph-cyl-axis-add) Color Quantity (packs) Additional GP Information Special Request Credit Card Information Card Type Required Select VISA Master Card Discover American Express Name on Card Required Card Number Required Expiration Date Required month 01 02 03 04 05 06 07 08 09 10 11 12 / year 2014 2015 2016 2017 2018 2019 2020 2021 2022 Security Code (if on card) Required Is the Credit Card Billing Address the same as in Patient Information section? Yes No If not, enter Credit Card Billing Address below: Address City State Zip Code Fraud Protection Warning: Processing of your order may be delayed if the name and address provided for this credit card do not match the billing address of the card. This order is subject to the expiration of product and quantity allowed by your prescription. If you have any questions or experience any problems using this page, contact our office at (217) 231-3937 ~ Toll Free (866) 231-3937 Ask Our Doctor Email Address* Ask Us A Question*PhoneThis field is for validation purposes and should be left unchanged. Patient Tools Schedule Appointment Reorder Contact Lenses Download Forms
