Contact Lens Order Form

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Contact Lens Order Form Powered By Docstoc
					                                     Contact Lens Reorder Form
Fill in the form below and fax to either 301-871-0183 or 703-691-0754. Your prescription and order will be
verified. You will be contacted if there are any questions. No more than a year’s supply will be honored.
FREE SHIPPING ON ALL ORDERS OVER $100.00 Shipping Charge $5.00
Type of contact Lens           Price/box     #of boxes                                 Total
1-2 week disposable
Clear
Accuve,ciba,cooper,B&l,          $21.00
Oasis                            $30.00
Advance                          $25.00
1 day                            $48.00

1 or 2 month
Replacement clear
Ciba, Actifresh, WJ, cooper,     $44.00
B&l,Sauflon
Night& Day Purevision            $72.00
Aspheric design                  $60.00

Astigmatic Std 1or 2
month Replacement
B&L, Cooper, Actifresh OSI       $99.00
Acuvue
Any custom toric                 $140.00

Bifocal 1 or 2 month
Acuvue, B&l, Proclear,           $150.00
Ciba,Unilens


Opaque/Enhancer
W/J, Ciba. Cooper                $69.00

Gas Permeable/Lens
Spherical                        $80.00
Bifocal                          $145.00
Custom                           $165.00


                                                                 Grand Total _________________

Credit Card Information:

CC#____________________________________________

Expiration Date: ___________________

Security Code : ___________________

Signature______________________________                       Date____________________

				
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