	Call (925) 460-5000 to schedule your free LASIK Screening or email us with any questions or comments:
	First Name: Last Name: E-Mail: Phone: Comments:

ORDER CONTACT LENSES

If you are a current patient and have had an eye examination within one year, and if you have not already ordered a complete year's supply of contact lenses, you may order lenses here.

PATIENT INFORMATION (* - Indicates required fields)

Patient Name*:

Date of Birth:*

ORDER LENSES

Please select :

Right eye.
Quantity of lenses

Left eye.
Quantity of lenses

If Boxes Ordered:
6 month supply 12 month supply

Pick up contact lenses at:

Pleasanton Livermore

DAYTIME PHONE: (925) 460-5000

Please allow approximately 5-7 business days for orders to be filled. We will notify you when your order arrives and if they are on back order.

If interested in direct shipment, orders must be paid in advance. Please call (925) 460-5000 to place an order for this service.

* Do you have vision benefits to use towards the purchase of this order?
Yes No

Name of Vision Plan:

None
Vision Service Plan (VSP)
Cole-Vision
One Medical
Eye Services
EyeMed
Davis Vision
Superior Vision

All lenses must be picked up within 2 weeks of notification. Payment in full is due when lenses are dispensed. We accept cash, Debit cards, VISA®, MASTERCARD®, or DISCOVER®.

Please notify me when the lenses arrive at

E-mail* (Enter a valid email address here):

Phone* (with area code):

If there is a problem with any aspect of your order, we will notify you. Thank you!