Please fill out the following form to re-order contact lenses. Required fields are marked with asterisks (*).

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

We must have a valid prescription for you on file. If we do not, please make an appointment with us for an eye exam. And YES, we can fill valid contact lens prescriptions from another office. Just fax your order to 360-253-2233.

 

About You

Patient Name
(Last, First, Middle Initial): *

Home Phone: *

Work Phone: *

Email Address: *

How do you prefer to be contacted? *

Email Phone  

Have you visited our office before? *

Yes No  

 

Your Order

Orders will be evenly split between right and left eyes unless otherwise indicated.

Click here to see our price list. For rigid gas permeable lenses or for soft contact lenses not listed, please call our office at (360) 253-4405.

Money-saving Mail-in Rebates are available on most annual supply orders.

Again, we can fill valid contact lens prescriptions from another office if you fax your order to 360-253-2233.

Quantity being ordered: *

Brand: *

Any additional information:

 

Shipping Information

Please select a shipping option: *

I will pick up the lenses at the office
Ship to the address below (shipping fee may apply)

 

Shipping address (if order is to be shipped to you)

Street Address:

City:

State:

Zip:

 

Payment by Credit Card

Required if order is to be shipped to you.

Credit Card Number:

CC Security Code:

Name on Card:

Expiration Date:

Billing Zip Code:

 
 

It may take a moment to submit your information. Please wait for a confirmation message.




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Mountain View EyeCare Center, P.C. | www.mtvieweyecare.com | 360-253-4405
14415 SE Mill Plain Blvd. Suite - 115B Vancouver, WA 98684



 

 

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