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Department of Ophthalmology and Visual Sciences


Contact Lens Refill Order Form

Please fill out the information form below. Our staff will contact you using the phone number you list to verify your order and to obtain credit card payment information from you.

Name:
Shipping Address:
City:
State:
Daytime Phone
Email Address :
Quantity of lenses needed  
Left:
Right:

Shipping:

 

Pickup
Delivery ($5 charge)

*NOTE* Free mailing for 1 year supplies

   
 

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Last modification date: Wed Jun 27 11:29:46 2007
URL: https://wws.uihealthcare.com /depts/med/ophthalmology/contactlens/orderform/lensorder.html