Contact Lens Order Page

 

 

This order form is provided as a "value added service" to our existing patients.  If you need replacement contacts, please fill out all parts of this form and submit it to us.  Once we receive your information we will review your chart and medical history, and if all is up to date you will be contacted by Pauletta to verify payment information.  The following information is secure.

Thank you,

Pauletta Bartley AOS Contact Lens Specialist

Please provide the following contact information:
First Name
Last Name
Date of birth (optional) 
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Best time to call
Work Phone
Home Phone

        Choose one of the following offices to pick up your lenses:

Thomas Office
Metro Office
Scottsdale Office

         Choose one of the following options:

Right lens
Left Lens
Both right and left

Type of Contact lens:



          Number of Lenses per eye:

How can we further help you?


        Return to home page

 
Copyright © 2008 [Affiliated Eye Surgeons]. All rights reserved.
Revised: 04/05/08