Contact Lense Order Form

You will receive a $5.00 courtesy discount 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.


First Name: *
Last Name: *
Birthdate:
Phone: *
Email: *
In regards to this order, I prefer to be contacted by:
 Email:
 Phone:
How many boxes for the Right Eye
How many boxes for the Left Eye
Please check YES if you would like for us to verify / use your insurance coverage on your purchase.
 Yes
Delivery Method
Address of Delivery:
Special Comment
Interested in LASIK? Request information regarding the most advanced all laser LASIK procedure to date
 Yes
Please type the letters and numbers shown in the image.
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**note: If you choose to have the lenses mailed, there may be a small mailing fee associated with the order