I have a prescription on file.

I am faxing a copy of my prescription.

First Name:

Last Name:

Middle Initial:

Date of Birth

We confirm all orders by phone before billing or shipping.

Email Address

Phone

Comments

Quantity

Use the credit card information and address information I provided at the time of my eye examination.

Yes No

I will contact you via phone or fax with my credit card and shipping information.

Yes No