Contact Lens Order Form

Contact Lens Order Form

Please fill out the following form to re-order contact lenses. Required fields are marked with asterisks (*).

The security of your information is very important to us. This form is fully secure and your information will be protected.

We must have a valid prescription for you on file. If we do not, please make an appointment with us for an eye exam.

  • About You

  • Your Order


    Orders will be evenly split between right and left eyes unless otherwise indicated.

    For prices, please visit our contact lens page. For rigid gas permeable lenses or for soft contact lenses not listed, please call our office at (360) 254-5855.
  • Shipping Information

  • Insurance Information

  • Payment


    Someone from our office will call you to process payment over the phone.