Please select an item.

Contact Lenses Order Form

Online orders are accepted only from existing patients to refill existing prescriptions. If you are a new patient, and wish to order contact lenses, please contact any of our Eye Centre Locations and one of our representatives will able to help you.

First Name: Please enter your first name.A value is required.A value is required.

Last Name: Please enter your last name.A value is required.A value is required.

A value is required.. Mailing Address: Please enter you address.A value is required.

City: Province : Please Select AB BC SK MN ON PQ NB NS PEI NF YK NWT NV Please select the province.

Postal Code: A value is required.Invalid format.

E-Mail:

Daytime Telephone Number (xxx) xxx-xxxx: A value is required.Invalid format. A value is required. Cell:

Date of Birth (mm/dd/yy): A value is required.Invalid format.

A value is requiredOrder Information

Eye Centre Location: Please Select Downtown Capilano Mayfield Leduc Westlock Please select a location

Quantity Required:

One-Year Supply

Six months Supply

Delivery Information

Call me when the order is ready. I will pick them up.

Please mail my contact lenses order and I agree to pay an additional $6.50 for deliver y.