Please fill out the following form to re-order contact lenses. Required fields are marked with asterisks (*).
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We must have a valid prescription for you on file. If we do not, please make an appointment with us for an eye exam.
Patient Name: *
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Orders will be evenly split between right and left eyes unless otherwise indicated.Click here to see our price list. For rigid gas permeable lenses or for soft contact lenses not listed, please call our office at (503) 722-7737 .
Quantity Being Ordered
-select-1 box2 boxes3 boxes4 boxes5 boxes6 boxes7 boxes8 boxes
-select-Acuvue 1-Day 30 pkAcuvue 1-Day Moist 30 pkAcuvue TruEye 30Acuvue TruEye 90Acuvue2 6 pkAcuvue Advance 6 pkAcuvue2 Color Opaque 6 pkAcuvue2 Color Enhancer 6 pkAcuvue Oasys 6 pkAcuvue Oasys for Astigmatism 6 pkAcuvue Oasys for Presbyopia 6 pkAcuvue Advance for AstigmatismBausch & Lomb Soflens66 Toric 6 pkBausch & Lomb Soflens Multifocal 6 pkBausch & Lomb PureVision 6 pkBausch & Lomb PureVision Multifocal 6 pkBausch & Lomb PureVision Toric 6 pkCiba O2 Optix 6 pkCiba Dailies AquaComfort Plus 30 pkCiba Dailies AquaComfort Plus 90 pkCiba Focus Night & Day 6 pkCiba Freshlook Enhancers 6 pkCiba Freshlook Colors/Blends 6 pkCiba Focus DailiesCooper Proclear 6 pkCooper Proclear Toric 6 pkCooper Proclear 1 Day 90 pkCooper Proclear Multifocal 6 pkCooper Clearsight 1 Day 90 pkCooper Frequency55 Aspheric 6 pkCooper Frequency55 Toric 6 pkCooper Vertex Toric 6 pkCooper Biofinity 6 pkCustom Spherical RGPCustom Toric RGPCustom Bifocal RGP
Any additional information:
Shipping rates: $8.00 in-state, $10.00 out of state.Free shipping when ordering an annual supply.
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I will pick up the lenses at the officeShip to the address below (shipping fee may apply)
Shipping address (if order is to be shipped to you)
Full payment is required at this time. Any applicable rebates will be mailed to you.
Total Order Amount ($): *
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Expiration Date: *
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