Downtown Vancouver Optometry Clinic - Optometrists and contact lens specialists.

Order Form


	Required fields
First Name	*
Last Name	*
Company
Address	*
City	*
Province/State	*
Country	*
Postal/Zip Code	*
Telephone	*
Cellular
Fax
Email	*

Special Instructions: (Quantity, shipping, note, etc).

	CREDIT CARD INFORMATION
Card Type	Visa Mastercard
Name on Card
Card Number
Expiry Date: mm/yy

	PLEASE SELECT PRODUCT
Replacement contact lens (for our existing patients)
Please send me a RIGHT contact lens (as noted in my file) Please send me a LEFT contact lens (as noted in my file) Please send me BOTH RIGHT and LEFT contact lens (as noted in my file)

*All deliveries made by commercial courier at rack rates unless otherwise arranged with our office.*