Order Contact Lenses
(
*
) denotes required fields
Name: (
*
)
Address: (
*
)
Address 2:
City:(
*
)
State: (
*
)
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
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NY
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ND
OH
OK
OR
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RI
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SD
TN
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WI
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ZIP: (
*)
Day Phone:
Cell Phone:
Email:
Select Quantity: (
*
)
Select Quantity
3 months supply
6 months supply
1 years’ supply
Credit Card
-----
Visa
MasterCard
Credit Card Number
Expiration Date
month
01
02
03
04
05
06
07
08
09
10
11
12
/
year
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Security Code
(CVC2 or CVV2)
BILLING ADDRESS
Same As Shipping Address
Name: (
*
)
Address: (
*
)
Address 2:
City:(
*
)
State: (
*
)
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP: (
*)
Day Phone:
Cell Phone:
Email:
Comments:
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