Huron Ophthalmology - Contact Lens Re-order Form

CONTACT LENS RE-ORDER FORM

 We at Huron Ophthalmology, P.C. want to make it easy and convenient for our patients to order additional contact lenses. Here are several ways you can order your lenses through our office:

*      Call our office at 734-434-6000 ext 205.  If our contact lens representative is busy,   you  can  leave a message for her or enter 0 for the operator to speak to another customer  service  representative.

  1. Fax your request by printing this sheet and sending it to our secure fax:  734-528-0720.  Please leave a message at 734-434-6000 ext 205 so we can confirm that your request has been received.
  2.  Leave an after hours voice mail for our contact lens representative at:   734-434-6000 ext 205.
  3. Go to the "patient portal" button and order online.

 

 

 All patients must have a valid (less than one year) contact lens Rx on file with us.

 

 Name:_________________________________________________________

            (First)                                     (Last)

 Date:_________________            Daytime telephone #______________________

 Credit Card # ______________________________(Visa, Mastercard, Discovery only)

    Card Expiration date __________   3 digit security code________

Name on Credit Card:______________________________________________

 Signature:______________________________________________________

  Order:   Right eye________ # of Boxes    OR      _________Lens(es)

               Left eye ________ # of Boxes      OR   _________Lens(es)

**Please indicate color when necessary.

□ Please ship UPS to:______________________________________________

                        Shipping usually takes 5-7 business days

□ I will pick up my contact lenses at Huron Ophthalmology, P.C.

  If you are picking up your contact lenses, you will be notified when your contact lens order is ready.  

 

 

 

 

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