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Contact Lenses Order Form

mandatory fields *

  Title: 
* Full name: 
Date of birth: 
* Day time telephone: 
* E-mail: 
(for confirmation email only, will not be given to a third party)
Health Insurance Number: 
(for identification)
* When was your last eye exam? 
An annual eye exam is recommended to all contact lenses users.
*  Type of lenses required:  Name of product:  

Right Eye         Left Eye

Quantity:
1 year       6 months      3 months

OR

Number of boxes:
Name of your optometrist: 

Comments:

    

    


    


    
 
Optometric Services Inc.