NEW CUSTOMERS

If you are not currently a customer of ours, please call us at 734-455-3350 or use the CONTACT FORM LINK and we will call you as soon as possible.

CURRENT PATIENT OR CUSTOMER

If you are a current patient or customer and would like to order your contact lenses online, please use the form below to submit your order  

We will confirm your order with a phone call.

PATIENT INFORMATION

First Name (required)

Last Name (required)

Phone (required)

Email (required)

Records on File

 Please check my record

LENS INFORMATION

Right Eye (OD)


Brand:

Box Qty:

Left Eye (OS)

 Same as Right Eye

Brand:

Box Qty:

BILLING INFORMATION


First Name: (required)

Last Name: (required)

Street 1: (required)

Street 2:

City: (required)

State: (required)

Zip: (required)

SHIPPING ADDRESS

Check here if Shipping Info is the same with Billing Info

First Name:

Last Name:

Street 1:

Street 2:

City

State

Zip

 Pickup Delivery ( Shipping Charge Additional )

Questions and/or Comments

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