Wufoo

Name First Last
Phone Number ### - ### - ####
Email
Your Optometrist
Dr. Beth Lennox Dr. Amanda Brown Dr. Charlie Alfano
Healthy Eyes Plan Reorder Quantity
6 month supply of contact lenses & solutions 12 month supply of contact lenses & solutions a different supply of contact lenses-specify supply below

We will fill your order using your current prescription. [You must have had an eye examination at our office within the past 2 years.]
amount if other than 6 or 12 month
Pick up/Delivery Options
I will come to the office to pick up please ship to my office address- shipping fee may apply please ship to my home address-shipping fee may apply

For shipping options, we will contact you for payment information. Your contact lenses will normally arrive in 2-3 business days. If you haven't received them after 4 days please contact our office at 519-624-2020.
Shipping Address if different from home address
Additional Comments/Special Requests
Thanks for ordering your contact lenses through our website!

We look forward to seeing you soon!
Do Not Fill This Out

Wufoo Powered