Discount Contact Lenses Printed Order Form

CALL: 1-800-822-9864FAX: 1-877-291-8154E-MAIL: sales@discountcontactlenses.comMAIL: 4265 Diplomacy Drive Columbus, Ohio 43228 United States

Your Order Information
Item Name / DescriptionEyePWRBCDIAPrice (each)QtyFinal Total
Sales Tax: 
Click Here to determine your shipping method and charge. Opens in a new window Shipping Method And Cost: 
Order Total: 

Your Prescription Information (please enter the Patient Name and Doctor Information below)
Please PRINT
Patient First Name:Middle Initial:Last Name:
Patient Date Of Birth (MM/DD/YYYY) (optional):
My current prescription is on file with Discount Contact Lenses.
I am including a copy of my prescription with this order form.
Please obtain my current prescription from my eye doctor, my doctor's information is provided below:
Doctor / Eyecare Provider Name:
Doctor / Eyecare Provider Phone:

I have read and agree to the Terms and Conditions found at Open dialog and the Notice of Privacy Practices found at Open dialog and I accept the above charge. (Your signature below is required.)
Please double-check that your order is complete and legible, especially the shipping address and phone number. Not providing a phone number or e-mail address could result in the delayment or unfulfillment of your order.
Checks and Money Orders should be made payable to: Arlington Lens Supply