LENS INFORMATION REQUEST

THANK YOU FOR SHOPPING WITH US!!!

Please arrange to have contact lens RX fax in or mail in prior to ordering.  Please FAX RX to 415-772-1904 or mail RX to Contact Lens Expo: 896 Stockton St, SF, CA 94108 or email ContactLensExpo@aol.com.

 


Filed with a * asterisk mark is a required field.

Right Eye OD

 

Left Eye OS

Lens Brand

Sphere RX

Reading ADD RX

Cylinder (Toric)

Axis

Base Curve

Diameter

Color (for Color Lens)

FOR RGP LENS PLEASE SPECIFY

Center Thickness

Peripheral Curve

Color (Tint)

For combination Color Lens or other special request, please type in the following box:

 

Is youe contact lens prescription valid?

YES     NO

Do you need new exam and / or lens fitting?

YES     NO

Have you been fitted for contact lens you request above?

YES     NO


*Last Name:

*First Name:

*Date of Birth:

(mm/dd/yyyy)

*Address:

*City:

*State:

 

*Country :

Zip Code :

 

*Email:

Home Tel # :

Cell Tel # :

Fax # :

Do you have an account with us before?

YES     NO

How did you hear about us?

CLE Member

TV

Friend & Associate

Eye Care Doctors

Other: