Contact Lens Order Form Need new contacts? Fill out our secure order form above, and we’ll get your lenses to you as soon as possible! Your Practice* Independence Sandusky Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Best Method To Reach You*SelectCallTextEmailEmail Address Contact Lens Order Amount* 6 months 1 year Other OtherApply Insurance Benefits?Do you have insurance benefits that you would like to apply to your purchase? Please give us your details:How would you like to receive your order? I'll pick it up. Ship it to me If you select “ship it to me” please watch for a text with a link to our payment portal. Order will be processed as soon as payment is completed Δ