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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Phone
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Hours

Closed 11:30am – 12:45pm on Wednesdays for staff meetings.
Closed all Stat Holidays.

Phone: (250) 477-7771
Fax: (250) 477-9903

201-3750 Shelbourne St
Victoria, BC
V8P 4H4