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Contact Lens Order Form - PDF

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Contact Lens Order Form - PDF Powered By Docstoc
					                                             The Optical Place                 Phone: 713-666-6691
The Optical Place                            4664 Beechnut                     Fax: 713-666-6658
                                             Houston TX 77096                  Email: doc@topdoc.com



  Contact Lens Order Form *required fields
   *Bill To:_________________________________                    *Ship To:(If different from mailing address)
                                                                 ___________________________________________
  *Billing Address_____________________________________

   Line2_____________________________________________            *Shipping Address_______________________________________

  *City______________________*State______*Zip_________           Line 2_________________________________________________

  Home Phone________________________________________             *City_______________________*State______*Zip____________

  Work Phone________________________________________

  Cell Phone_________________________________________
                                                                  *Perscribing   Eye Doctor
  *Email____________________________________________

  *Credit Card Holder_________________________________            *Doctor’s Name_________________________________________

  *Credit Card Number________________________________             *Doctor’s Phone_________________________________________

  *Credit Card Expiration______________________________           *Doctor’s Fax___________________________________________




       Contact Lens   Contact Lens   Contact Lens Contact Lens   Left Eye or   Contact Lens      Number of    Unit Price or
          Brand          Type         Base Curve     Power        Right Eye       Color            Boxes     Package Price




                                                                                              Subtotal

                                                                                              Tax




  INSTRUCTIONS:                                                                               Balance Due

  Print and fill out form then
  Fax to 713-666-6658
  OR
  Mail completed form to
  The Optical Place                                                                      The Optical Place
  4664 Beechnut
  Houston TX 77096                                                                       www.topdoc.com
  Thank you from the The Optical Place team.

				
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Description: Contact Lens Order Form document sample