Contact Lens Order Form -Davis Eye Center

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First Name:
Last Name:
Birthdate:
Phone:
Email:

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In regards to this order, I prefer to be contacted by: Phone    Email

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How many boxes would you like to order?

** You will receive a $5.00 courtesy from Davis Eye Center with a 4-box purchase or a $10 courtesy with a 8 box purchase.

** Many manufacturers offer a mail in rebate on certain quantities if purchased within a specific time frame from your examination. We will provide rebate information if applicable when we contact you.

Right Eye:	style="WIDTH: 100px; HEIGHT: 22px"> Select One 1 box 2 boxes 3 boxes 4 boxes 5 boxes 6 boxes 7 boxes 8 boxes 9 boxes 10 boxes 11 boxes 12 boxes same quantity as last order none for the right eye
Left Eye:	style="WIDTH: 100px; HEIGHT: 22px"> Select One 1 box 2 boxes 3 boxes 4 boxes 5 boxes 6 boxes 7 boxes 8 boxes 9 boxes 10 boxes 11 boxes 12 boxes same quantity as last order none for the left eye

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If ordering for multiple family members please provide their names and the quantities of boxes desired in the "Additional Information" box below:

Additional Information:

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Insurance?

Yes    No

Please check YES if you would like for us to verify / use your insurance coverage on your purchase.

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Delivery Method: If you choose to have the lenses mailed, there may be a small mailing fee associated with the order

Delivery Method:	style="WIDTH: 100px; HEIGHT: 22px"> Select One I will pick them up at the office Please deliver to home address Please deliver to alternative address

If choosing to have your order shipped to alternative address be sure to list that address in the box below

Alternative Address:

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As a reminder, you are submitting this request over the internet. Please do not include any sensitive medical information or credit card information in your order request, for we cannot guarantee that other parties will not see it. We will obtain payment information when we contact you.

Special Instructions: (if any)

 Interested in LASIK? Check this box to request information regarding the most advanced            all laser LASIK procedure to date. Our director of laser vision correction will get back to you!

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