Patient Name *

First Name

Last Name

Patient Date of Birth *

MM

DD

YYYY

Phone *

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Shipping Address

This is where your order will be shipped to. Not required if selecting In-Store Pickup.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Supply Size *

Please select one of the following options. Some brands may have minimum box sizes and we will notify you if applicable.

12 Month Supply [Best Value & Eligible for Manufacturer Rebates. See Links Below]

6 Month Supply

3 Month Supply

Shipping Speed *

Free Standard shipping with 6 month supply of Daily Disposable lenses, or 12 month supply of all other contact lenses

Standard (5-10 Days) $15 or Free with Eligible Order

Expedited (3-5 Days) $30

In-Store Pickup (3-5 Days) Free. Our team will contact you when your order is ready for pickup.

Payment Method *

Please select your preferred payment method

Credit / Debit Card / HSA / FSA

Charge Existing Card on File

Bitcoin or Other Cryptocurrency

Care Credit

Other (Please indicate in Additional Information field)