ORDERFORM

Due to fluctuations in the currency exchange and cost pricing, we are unable to list product prices on our website.  We will be more than happy to quote you a current, competitive price if you provide us with the following information. 

 If you have concerns about security, you may print and fax the form to (604) 682-3314.  To check the status of your order or if you have any other questions, please call our office at (604) 681-5351

 Name: 
Address: 
City: 
Province/State:
Country:
Postal/Zip Code:
Telephone:
Fax:
Email:
    

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

 

  Credit Card Information
Card Type: Visa     MasterCard
Name on Card:
Card Number:
Expiry Date:


PLEASE SELECT PRODUCT 

1) 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 & LEFT contact lenses (as noted in my file)

2) CIBA Dailies (Doctor's authorization required)
  
  90 wears  
 
3) CIBA Night and Day (Doctor's authorization required)
  
         6 month supply 

4) CIBA Focus Bifocal Soft Lenses (Doctor.'s authorization required)
    
       1 box of  6

5) Allergan's Ultra Care
 
          3 month supply

6) CIBA Solo Care
  
         2 x 360ml bottles and a new lens care

7) Allergan Complete
           2 x 360ml bottles plus a 60ml traveler bottle & a new lens case
     

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


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Downtown Vancouver Optometry Clinic
Toronto Dominion Bank Tower
1440-700 West Georgia Street
Vancouver, B.C. Canada  V7Y 1C6
Ph. 604-681-5351  Fax: 604-682-3314  email: info@myeyesonline.com

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