Order Contact Lenses

Free Text

Patient First Name

Patient Last Name

Patient Date of Birth

Phone Number

Email Address

Mailing Address

City/Town

State

Zip Code

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CONTACT LENS PRESCRIPTION

Brand

Date of Rx

Doctor

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Power Right Eye

sph

cyl

axis

b.c.

diam

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Power Left Eye

sph

cyl

axis

b.c.

diam

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Do you wish to order a years supply?

Yes

If NO - where did you receive your contact lens prescription?

Please upload a copy of your current prescription if you are NOT a Goldthwait Vision Care patient.

Do you plan to use your Eyemed material allowance toward your purchase?

Yes

Preferred Method of Contact?

Phone

Any other questions or concerns?

Free Text

Thank you, we will do our best to respond within 48 hours.

The order is NOT placed until we have spoken with you directly, received payment, and verified the contact lens prescription.