Contact Lens Order Form

If you are a current customer of the EyeCare Associates LLC, you can order your contact lenses online. Please be sure to include all of your contact information in the order form so that we can contact you if we have any questions.

Personal Information

Patient's First Name
Middle Name
Last Name
Patient's Street Address
Apt. No./Suite (if applicable)
City State Zip Code

Date of Birth (mm/dd/yyyy)
Daytime Phone
E-mail Address (Required so that we can confirm receipt of your order)

Contact lens you are ordering

Quantity - Right Eye	Quantity - Left Eye
Brand (if known)
Color (if applicable)

Additional instructions or comments:

Delivery Options

Mail by USPS to the above address for no additional charge

--OR---

Mail by USPS to the following shipping address for no additional charge:


	Shipping Street Address Apt. No./Suite (if applicable) City State Zip Code

--OR--

Pick up at one of our locations

	Select an office location Who should we notify when the order has arrived? Name: Phone:

Payment

Pay for when picked up

Mailing check to EyeCare Associates, LLC 222 East 6th Street, York, NE 68467

Please note that your personal information and email address will be used solely for the purposes of processing your order. Email addresses are not shared or sold to other parties.

Your order will be submitted to EyeCare Associates via email. We will contact you at the phone number listed above if there are any questions about your order. Thank you for using EyeCare Associates.