- Order Contacts -
PATIENT NAME
:
New Patient
PRODUCT:
---------------- Product List ----------------
Acuvue Advanced ($33.00/box)
Auvue Advanced Toric (Astig) ($48.00/box)
Acuvue Oasys (38.00/box)
Acuvue Dallies ($33.00/box)
Bausch and Lomb Soflens Multifocal ($75.00/box)
Bausch and Lomb Purevision ($70.00/box)
CIBA Focus Dailies ($60.00/box)
CIBA 02 Optix ($25.00/box)
CIBA Freshlook Colorblends ($45.00/box)
Cooper Proclear ($55.00/box)
Cooper Proclear Bifocal ($80.00/box)
Cooper Proclear1-Day 90 Pack ($70.00/box)
Cooper Clearsight 1-Day Pack ($60.00/box)
Cooper Purevision ($70.00/box)
OSI Definition AC ($40.00/box)
Other Product (fill in type in "message" area)
Current Patient
RIGHT EYE:
Power:
Base Curve:
LEFT EYE:
Power:
Base Curve:
RIGHT EYE:
# of Boxes:
(quantity)
LEFT EYE:
# of Boxes:
(quantity)
SHIP TO
:
My Home Address ($7.00 shipping and handling will be added for orders of 3 boxes or less)
Street
City
State
Zip
SHIP TO
:
Eyedentity
Call me when in
Phone:
Email me when in
Email:
PAYMENT INFORMATION
Credit Card
Check
Cash
Other
Message: (Do not put credit card numbers on this form)
Shortly after submitting your order Eyedentity will contact you for final authorization.
