Re-Order Contact Lenses

All contact lense re-orders are processed in our office. Please fill out the form below and our staff will contact you within 1-2 days to collect credit card billing information and complete your order.

Patient Information
Name*
First Last
Phone*
Email
Date of Birth*
MM slash DD slash YYYY
I Have Insurance Benefits for Contact Lenses
- Yes
- No
Contact Lens Information
Right Eye (OD)
Left Eye (OS)
Lens Manufacturer (right)
Lens Manufacturer (left)
Lens Brand (right)
Lens Brand (left)
Power (right)
Power (left)
Diameter (right)
Diameter (left)
Base Curve (right)
Base Curve (left)
Right Eye (OD)
Left Eye (OS)
Box Quantity (right)
Box Quantity (left)
Billing & Shipping
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Shipping Options
Flat rate $7.00 shipping for any order less than year supply.
- Pick up at Office
- Shipped to Your Home
Shipping Address Same as Billing Address
- Yes
- No
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Questions/Comments

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Re-Order Contact Lenses

Patient Information

Contact Lens Information

Right Eye (OD)

Left Eye (OS)

Billing & Shipping

Call (248) 620-3000 to Schedule Your Appointment Today!

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