Order Contact Form

Please enter the required information below. Information submitted within normal business hours will be processed within 24 hours. Please allow 7-10 business days for the order to arrive.
Expect an additional delay for orders placed during non-business hours.

(*) Required Fields

(*)First Name:

(*)Last Name:

(*)Address:

(*)City:

(*)State:

(*)Zip:

(*)Contact Phone:

(*)Date of Birth(MM/DD/YYYY):

(*)Email Address:

Debit/Credit Card

(*)Credit Card Holders Name :

(As it appears on the card)

(*)Credit Card Type:

(*)Credit Card Number:

(*)Expiration Date: /

(*)Security Code:

(*)Amount to be charged:

(*)Boxes for Right Eye :

(*) Type of Lens (Right Eye) :

Lens Color (If applicable) :

(*)Boxes for Left Eye :

(*) Type of Lens (Left Eye) :

Lens Color (If applicable) :

(*) Method of Delivery :

Remember, this is how we ship them once we get them. It will take up to 7-10 business days before we ship them.

Additional Comments
Please enter any other information (i.e. lens color) when applicable :

By pressing the 'Submit Form' button, you will be authorizing Clay Eye Physicians/Fleming Island Optical to charge your credit card in the amount necessary to order your contact lenses. The prices listed are only a rough estimate of your total charges and may be adjusted to reflect current prices. The current prices will be determined by the most current price list maintained at Clay Eye Physicians. Please call us at (904) 272 - 2020 if you have any questions.

Please be aware that this form may be used only to re-order contact lenses from a current prescription, not to order them for the first time. If you would like to purchase contact lenses for the first time, you may visit one of our Optometrists for a complete eye exam