Last Name:

First Name:

Date of Birth:

SSN:

Phone:

Alt Phone:

Email:

Address:

City/State:

Zip:

Contact Brand (ie. Acuvue Oasys)

Click here for Price List

Number of Boxes:

30 pack

90 pack

* Daily Disposable only

Prescription:

BC

Dia

PWR

OD (R)

OS (L)

Prescribing Doctor:

Delivery Method:

Pick Up

Shipped (Free Ground Shipping)

All Contact Lens orders receive a free travel bottle of solution and lens case.

Please choose solution:

At the Eye Specialists of Mid Florida we also recognize you may have insurance coverage for your contacts. If you would like to use your insurance please let us know in the detail section below. Please be sure to include your insurance carrier ID number, group number and the 1-800 number listed on your card.
If you have any questions please contact us at: contactlens@EyesFL.com

Details you would like us to know:

Insurance Policy: All amounts not covered by an insurance company will be the sole liability of the patient.

Return Policy: We will be happy to exchange unopened, unexpired boxes of contact lens with no markings for up to one year. All Colored Lens sales are final. Please contact our Contact Lens department if you have any questions about returning your contacts.