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Contact Lens Order Form
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
Province
*
Postal Code
*
Phone #
*
Email
*
Quantity
*
1 year supply
6 months supply
3 months supply
Insurance
*
I would like my insurance billed
I do not have insurance or do not want to bill it
Delivery
*
I would like my contact lenses delivered to the above address. One of our staff members will contact you to finalize the order.
Pick up contacts in clinic. A staff member will contact you when the order has arrived.
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