Optical Shop: Re-Order your Contact Lens'

For the convenience of our existing patients, we are pleased to offer the option of reordering your contact lenses online.
If you are not an existing patient, we would love the opportunity to fit you. Please make an appointment at one of our convenient locations.

Re-Order Information:

Name:

Birthdate: (MM/DD/YYYY)
/ /

Daytime number *

Mobile number

E-mail address *

Type of lenses to be ordered:

Quantity:
Color:

Special Instructions?

Any insurance being filed?

No Yes

Insurance provider:

Insurance Policy holder's name:

Delivery Options:

I will pick-up my contact lens order at one of your clinics.

I prefer to be notified when my order is ready for pick-up by:
phone e-mail

I would like you to mail my contact lens order.
An $8.00 postage and handling fee will be applied.

If you would like your contact lenses mailed to you, we must have your credit card information on file in our office. If you do not, please call our main office at (281) 488-7213 select option 3 to place your information in a confidential file.

Mailing Information:

Name:

Address:

City:

State:

Zip: