Contact Lens Reorder Form

Note: You must fill in all the required fields

First Name: 

Last Name: 

Email Address:

Daytime phone number(cellphone preferred):

Pick-up Options:      OR     
Address:
Province/State:
City:
Postal/Zip:  
Country:

We will use your current prescription for the order.
You will be contacted if your current prescription is no longer valid.


Optometrist's name (Optional):  

Quantity:           


Additional Comments: (Optional)



Human test:

CAPTCHA Image Reload Image


Enter Code Here:  

 


      
 Home   |  About Us   |   Our Clinic   |  Our Services   |  Useful Info   |  Contact Us

2024 © EyeconX. All rights reserved