Ohio Eye Care Consultants - Contact Lens Order Form

Dr. Thomas Chi, Dr. Amy Fernandez and Dr. Carrie Balthaser

CONTACT LENS ORDER FORM

To request contact lenses, please fill out the form below.

Patient's Name*
First Name: MI:
Last Name:

Street Address
Address:
City: State: Zip:

Phone* (Please enter at least one)
Home:
  Cellular:
  Work:

E-mail Address*

I prefer to be contacted by:
Phone E-mail

How many would you like to order?*
Right Eye:

Left Eye:

You will receive $2.00 off each box when you order one year's supply of contacts.
If your order is eligible for any manufacturer's rebate, we will mail them to you.

Shipping Method*

Please understand that you are submitting this request over the Internet. Do not include any sensitive medical information or credit card information in your order request, for we cannot guarantee that it will not be seen by other parties. We will obtain additional medical and payment information when we contact you.

Additional Information

Back to the top