CONTACT LENS ORDER FORM
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Patient Information
*If the Patient is also the person that is responsible for the bill, check
here
Prescription
On File
Will fax to 781.229.2025
Call my Doctor
(
)
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Right Eye Quantity Boxe(s) or Vials
1
2
3
4
5
6
7
8
9
10
11
12
Left Eye Quantity Boxe(s) or Vials
1
2
3
4
5
6
7
8
9
10
11
12
Lenses
Bill to Information
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MS
MT
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Phone
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*If the billing & shipping information are the same, check
here
Ship to Information
state
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Payment
Payment Method
MasterCard
Visa
AMX
Discover
Bill Card on File (Re-Order Only)
Send Bill with CL's (Prior Approval)
Mth
01
02
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04
05
06
07
08
09
10
11
12
Yr
Many manufacturers offer rebates on quantity orders. If you would like additional information,
put a check here
and enter your telephone # in the "notes" box below, for us to call you.
notes:
delivery type
Regular Ground 2-3 Business Days- $9.49
Saturday, March 30, 2024 Delivery cost-$30
I will pick up at the Office
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read/agree
to the terms
: