Order Contacts

Please fill out the information below, and we will contact you to confirm your order, give you final pricing, and rebate information if applicable.

Name (required)

Email (required)

Phone Number (required)

Select an Office (required)

Are you a patient of our office?

YesNo

If you are not a patient of our office, please upload a current prescription.

Supply Option

Using Insurance

YesNo

Please provide the name of your vision insurance.

Are you the primary on the insurance and if not, please provide the information of the primary.

Preferred Method of Contact

Which method of payment were you planning to use for this order?

How would you like us to contact you for payment?

Via TelephoneEmail an invoice that can be paid online

How would you like us to contact you for payment?

Via Telephone

Which address would you like these contacts shipped to? (required)

Additional Comments

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