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Contacts Ordering Form

Please fill in the information in the form below regarding the contact lenses you would like to order. All online orders will require a phone confirmation.

Family Name:
First Name:
Phone Number:
Email (optional):
Your current contact lens brand:
Right Lens Base Curve:
Right Lens Diameter:
Right Lens Power:
Left Lens Base Curve:
Left Lens Diameter:
Left Lens Power:
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