Name:
Email:
Day Phone:
The number of boxes
of contacts
you would like to order:
Date Needed:
The contact lens manufacturer can ship ($7.00 manufacturer’s fee)
the lenses directly to your home or office,
or you can pick them up at the office during regular business hours.
Shipping:
Ship to me:
| Pick-up:
*
Please Note:
There is a federal law governing the expiration
of a contact lens prescription. We will verify your prescription
expiration date before calling you about your contact lens order.
Submit
100 East Nasa Road 1 @ Hwy 3 Webster, Texas 77598
