Print this form to place an ORDER by FAX
FAX #: 323-583-1344

New Customer___ Current Customer ___

Name:________________________________________________________

E-Mail:______________________________________________ (You will receive your shipping confirmation via email, please make sure you enter your email address correctly)

Address:_______________________________________________________(Sorry we do not ship to P.O.Boxes)

City:_________________________________State/Province:____________________

Zip/postal Code:___________________ Country:_____________________________

Home Telephone:_________________________

Prescription Information

Name of person lenses are for (if different than above):_____________________________

Doctors name: _____________________________Telephone ( )______-__________

Last exam (Month/year)_____/_____

Contact Lens Specifications:

Brand name:________________________________Type:___________________

If lenses come in colors, indicate color:___________________________________

Prescription (Rx)
RIGHT EYE (OD)
LEFT EYE (OS)
example

Power:

.

.
-1.75

Base Curve: (BC)

.

.
8.8

Dia.

.

.
14.0

FOR TORIC LENSE ONLY

Cylinder

-1.50

Axis

90

FOR BIFOCAL LENSES ONLY

ADD Power

+1.50

Quantity you like to order:(if disposables, specify quantity of boxes for each eye)

Right Eye:__________ Price Each:_____________

Left Eye: ___________ Price Each: _____________

Shipping Method:(International destinations outside the US, shipped registered mail only)
___UPS Ground in most States $9.95 (5-7 days)
___Alaska, Hawaii, Puerto Rico, Guam $25.95
___UPS (2nd Day) $19.95, ___UPS (next day) $48.95, ___Registered Mail $30.00
Note: 2nd Day and Next Day shipping are subject to stock availability, special order items will have
longer lead time.

Automatic Shipping: Would you like future orders shipped automatically?: Yes___ No___
Specify frequency: every 3 months___ 6 months___ 9 months___ 12 months___

Payment Method: Visa___ Mastercard___Amex___Discover___Check/Money Order___

Credit Card number:_____________________________________Expiration date:_____/_____

Credit Card Billing Address (if different from shipping address)

Address__________________________________________________________

City_______________________________State_________ Zip/Postal Code__________________________

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