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Contact Lens Order Form
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
Province
*
Postal Code
*
Daytime Phone
*
Email
*
Quantity
*
Repeat my last contact lens order
1 year supply
6 months supply
3 months supply
Delivery
*
I would like my contact lenses delivered to the above address. One of our staff members will call to finalize the order.
Pick up contacts in clinic. A staff member will call when the order has arrived.
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