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Contact Lens Email Order Form

We are happy to refill your contact lens order. It is important that contact lens wearers have annual or bi-annual eye examinations to maintain optimal comfort, vision and eye health. Your eye health is very important to us so we will review your file before ordering your contact lenses.

You can pick the lenses up at our office or can we arrange to have them mailed to you.

First Name (required)

Last Name (required)

Your Email (required)

Daytime phone (required)

Brand of contact lens

Colour of contact lens

Which eye?
LeftRightBoth

Quantity
1 month3 months6 months1 yearsame as last time

If the contact lenses you are wearing are available at a price savings for larger quantities would you like us to contact you with the details ?
yesno

Question/Comments

NOTE: You will receive an email confirmation that we have received your order. If you have not heard from us within 2 business days, please call our office at 519-885-2701.