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Contact Lens Reorder

For your added convenience, you can now re-order your contact lenses online by using our easy order form. You no longer need to come in or call us to order your contacts. Just complete the form and submit it and we will contact you when your contacts come in.

Please Note: We cannot re-order your contacts if your prescription has expired. Contact Lens prescriptions are valid for one year.

Complete the form and click Submit at the bottom of the page. An e-mail confirmation will be sent to you.

* = required
Patient Information
Name: *
Date of Birth: *
Daytime Phone (if we have questions): *
E-mail Address:
(include if you would like to receive confirmation)		 *
 
Order InformationBoxes per eye (0 if none)
Right: *
Left: *
Brand:
 
Pickup/Shipping Information
Pickup at Carrollton Office
Pickup at Villa Rica Office
Ship to Billing Address
I'll enter the shipping address
Address:
City:
State: ex: GA, FL
Zipcode:
 
Billing Information
Name on Card:
Card Type:
Card #:
Expiration Date:
Security Code:
Address:
City:
State:
Zipcode:
 
Additional Information
Comment: