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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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 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 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 PackMessageEmailThis field is for validation purposes and should be left unchanged.
