Contact Lens Order Request

Please use this form to request contact lens orders. Our staff will contact you to confirm the order details and/or collect payment.

Please note: Per federal regulations, contact lens prescriptions expire one year after the date of the exam. You may need a new exam to update your prescription before you can place an order. Please be sure to schedule annual exams well in advance to maintain a valid prescription.

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Office Location *

Burlington

Essex Junction

Name *

First

Last

Date of Birth *

Day

Month

Year

Phone or Email Address (so we can confirm your order) *

Would you like to bill insurance for this order? *

Yes

No

How much would you like to order? *

3 months

6 months

12 months

Shipping Options (Direct ship orders must be paid in advance) *

Notes