Order Contact Lense Online From Homer Township Vision Center

ORDER CONTACT LENSES

Please complete all fields: *=required

Name:*

Address:*

City, State, Zip :*

Email Address:*

Phone Number:*

Prescription Information:

Are you a current patient of Homer Township Vision Center? * Yes No If not, do you have a current contact lens prescription? * Yes No If yes, please fax a current prescription to 708-301-0884. **We cannot fill a contact lens order without a current valid prescription. -or- I do not have a copy of my prescription. Please enter the following information:
Prescribing Doctor's Name:
Office Phone Number:

Please order the following:* boxes for left eye boxes for right eye

When the contact lens order is completed: *

Please ship to the address above. ($10.00 shipping fee.)

Please ship to the following address: ($10.00 shipping fee.)
Address:
City/State/Zip: ,

Contact me by e-mail.

Call me at the above number.

Form of Payment*

I will pay when I pick up the contact lenses

Please call for my credit card information

(Lenses will not be shipped until payment is made.)

To schedule an appointment please call 708-301-2020