Contact Lens Order Form

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Name:*
Address:
City:
State:
Zip:
Daytime Phone:
Email:*
Date of Birth:

	Order Information: *Indicate order quantity.*
HOW MANY WOULD YOU LIKE TO ORDER?	Right Eye: Left Eye:
SHIPPING METHOD?
Please understand that you are submitting this request over the Internet. Do not include any sensitive medical information in your order request, for we cannot guarantee that it will not be seen by other parties. Orders will be placed within 24 hours of your request. You will be contacted by phone (provided above) to confirm your order. If you need to contact us call 305-598-2020, ext. 1033 or e-mail contactlenses@centerforeyecare.com.

Additional Information:

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