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Contact Re-Order Form Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern 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CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pickup Options(Required)Pickup at Visualeyes (3945 Main St)Pickup at Visualeyes (735 Elmwood Ave)Ship to MeRight Eye Lens Type30 Day14 Day1 DayRight Eye Lens Quantity1 box2 boxes3 boxes4 boxesRight Eye Lens ManufacturerAlconBausch & LombCooperMeniconVistakonX-Cel SpecialityAlcon Lens ChoiceAir Optix + Hydraglyde – (30 Day) 6 PackAir Optix + Hydraglyde Multifocal – (30 Day) 6 PackAir Optix + Hydraglyde Astigmatism – (30 Day) 6 PackAir Optix Aqua Night & Day – (30 Day) 6 packAir Optix Colors – (30 Day) 6 PackAir Optix Colors – (2 pks)Dailies AquaComfort Plus – 30 PackDailies AquaComfort Plus – 90 PackDailies AquaComfort Plus Toric – 30 PackDailies AquaComfort Plus Toric – 90 PackDailies AquaComfort Plus Multifocal – 30 PackDailies AquaComfort Plus Multifocal – 90 PackDailies Colors – 30 PackDailies Colors – 90 PackFocus Dailies – 30 PackFocus Dailies – 90 PackPrecision 1 – 30 PackPrecision 1 – 90 PackPrecision 1 Astigmatism – 30 PackPrecision 1 Astigmatism – 90 PackTotal 1 – 30 PackTotal 1 – 90 PackTotal 1 for Astigmatism 30 PackTotal 1 for Astigmatism 90 PackTotal 1 Multifocal – 30 PackTotal 1 Multifocal – 90 PackBausch & Lomb Lens ChoiceBiotrue 1 Day – 30 PackBiotrue 1 Day – 90 PackBiotrue 1 Day Astigmatism – 30 PackBiotrue 1 Day Astigmatism – 90 PackBiotrue 1 Day Presbyopia – 30 PackBiotrue 1 Day Presbyopia – 90 PackInfuse 1 Day – 90 PackSoflens – (14 Day) 6 PackSoflens Multifocal – (14 Day) 6 PackUltra – (30 Day) 6 PackUltra Astigmatism – (30 Day) 6 PackUltra Presbyopia – (30 Day) 6 PackUltra Multifocal/Astigmatism – (30 Day) 6 PackCooper Lens ChoiceBiofinity Energys – (30 Day) 6 PackBiofinity EW – (30 Day) 6 PackBiofinity Multifocal – (30 Day) 6 PackBiofinity Toric – (30 Day) 6 PackBiofinity Toric Multifocal – (30 Day) 6 PackBiofinity XR – (30 Day) 6 PackBiofinity XR Toric – (30 Day) 6 PackClariti 1 Day – 30 PackClariti 1 Day – 90 PackClariti 1 Day Multifocal – 30 PackClariti 1 Day Multifocal – 90 PackClariti 1 Day Toric – 30 PackClariti 1 Day Toric – 90 PackMyDay 1 Day – 90 PackMyDay 1 Day – 180 PackMyDay Toric 1 Day – 90 PackMyDay Multifocal 1 Day – 90 PackProclear 1 Day – 90 PackProclear 1 Day Multifocal – 90 PackProclear Compatibles – (30 Day) 6 PackProclear Multifocal – (30 Day) 6 PackProclear Multifocal Toric – (30 Day) 6 PackProclear Toric – (30 Day) 6 PackProclear Toric XR – (30 Day) 6 PackMenicon Lens ChoiceMiru 1 Day – 30 PackMiru 1 Day – 90 PackMiru 1 Day Toric – 90 PackMiru 1 Day Upside – 90 PackVistakon Lens ChoiceAcuvue 2 – (14 Day) 6 PackAcuvue Moist – 30 PackAcuvue Moist – 90 PackAcuvue Moist 1 Day Astigmatism – 30 PackAcuvue Moist 1 Day Astigmatism – 90 PackAcuvue Moist 1 Day Multifocal – 90 PackAcuvue Moist 1 Day Multifocal – 90 PackAcuvue Oasys 1 Day – 90 PackAcuvue Oasys 1 Day Astigmatism – 30 PackAcuvue Oasys 1 Day Astigmatism – 90 PackAcuvue Oasys – (14 Day) 12 PackAcuvue Oasys – (14 Day) 24 PackAcuvue Oasys Astigmatism – (14 Day) 6 PackAcuvue Oasys Multifocal – (14 Day)Acuvue Oasys Transition – (14 Day) 6 PackX-Cel Speciality Lens ChoiceExtreme H2O 1 Day – 30 PackExtreme H2O 1 Day – 90 PackExtreme H2O – (30 Day) 6 PackLeft Eye Lens Type30 Day14 Day1 DayLeft Eye Lens Quantity1 box2 boxes3 boxes4 boxesLeft Eye Lens ManufacturerAlconBausch & LombCooperMeniconVistakonX-Cel SpecialityAlcon Lens ChoiceAir Optix + Hydraglyde – (30 Day) 6 PackAir Optix + Hydraglyde Multifocal – (30 Day) 6 PackAir Optix + Hydraglyde Astigmatism – (30 Day) 6 PackAir Optix Aqua Night & Day – (30 Day) 6 packAir Optix Colors – (30 Day) 6 PackAir Optix Colors (2 pks)Dailies AquaComfort Plus – 30 PackDailies AquaComfort Plus – 90 PackDailies AquaComfort Plus Toric – 30 PackDailies AquaComfort Plus Toric – 90 PackDailies AquaComfort Plus Multifocal – 30 PackDailies AquaComfort Plus Multifocal – 90 PackDailies Colors – 30 PackDailies Colors – 90 PackFocus Dailies – 30 PackFocus Dailies – 90 PackPrecision 1 – 30 PackPrecision 1 – 90 PackPrecision 1 Astigmatism – 30 PackPrecision 1 Astigmatism – 90 PackTotal 1 – 30 PackTotal 1 – 90 PackTotal 1 for Astigmatism 30 packTotal 1 for Astigmatism 90 packTotal 1 Multifocal – 30 PackTotal 1 Multifocal – 90 PackBausch & Lomb Lens ChoiceBiotrue 1 Day – 30 PackBiotrue 1 Day – 90 PackBiotrue 1 Day Astigmatism – 30 PackBiotrue 1 Day Astigmatism – 90 PackBiotrue 1 Day Presbyopia – 30 PackBiotrue 1 Day Presbyopia – 90 PackInfuse 1 Day – 90 PackSoflens – (14 Day) 6 PackSoflens Multifocal – (14 Day) 6 PackUltra – (30 Day) 6 PackUltra Astigmatism – (30 Day) 6 PackUltra Presbyopia – (30 Day) 6 PackUltra Multifocal/Astigmatism – (30 Day) 6 PackCooper Lens ChoiceBiofinity Energys – (30 Day) 6 PackBiofinity EW – (30 Day) 6 PackBiofinity Multifocal – (30 Day) 6 PackBiofinity Toric – (30 Day) 6 PackBiofinity Toric Multifocal – (30 Day) 6 PackBiofinity XR – (30 Day) 6 PackBiofinity XR Toric – (30 Day) 6 PackClariti 1 Day – 30 PackClariti 1 Day – 90 PackClariti 1 Day Multifocal – 30 PackClariti 1 Day Multifocal – 90 PackClariti 1 Day Toric – 30 PackClariti 1 Day Toric – 90 PackMyDay 1 Day – 90 PackMyDay 1 Day – 180 PackMyDay Toric 1 Day – 90 PackMyDay Multifocal 1 Day – 90 PackProclear 1 Day – 90 PackProclear 1 Day Multifocal – 90 PackProclear Compatibles – (30 Day) 6 PackProclear Multifocal – (30 Day) 6 PackProclear Multifocal Toric – (30 Day) 6 PackProclear Toric – (30 Day) 6 PackProclear Toric XR – (30 Day) 6 PackMenicon Lens ChoiceMiru 1 Day – 30 PackMiru 1 Day – 90 PackMiru 1 Day Toric – 90 PackMiru 1 Day Upside – 90 PackVistakon Lens ChoiceAcuvue 2 – (14 Day) 6 PackAcuvue Moist – 30 PackAcuvue Moist – 90 PackAcuvue Moist 1 Day Astigmatism – 30 PackAcuvue Moist 1 Day Astigmatism – 90 PackAcuvue Moist 1 Day Multifocal – 90 PackAcuvue Moist 1 Day Multifocal – 90 PackAcuvue Oasys 1 Day – 90 PackAcuvue Oasys 1 Day Astigmatism – 30 PackAcuvue Oasys 1 Day Astigmatism – 90 PackAcuvue Oasys – (14 Day) 12 PackAcuvue Oasys – (14 Day) 24 PackAcuvue Oasys Astigmatism – (14 Day) 6 PackAcuvue Oasys Multifocal – (14 Day)Acuvue Oasys Transition – (14 Day) 6 PackX-Cel Speciality Lens ChoiceExtreme H2O 1 Day – 30 PackExtreme H2O 1 Day – 90 PackExtreme H2O – (30 Day) 6 PackMessagePhoneThis field is for validation purposes and should be left unchanged.
