Contact Lens Email Order form

Kindly fill in all the required fields below.
First name:   *
Last name:   *
Date of birth:   open calendar      *
Daytime phone:   *
Cell phone: 
E-mail:   *
  Note: Your email address is only for confirmation and will not be used for any other purpose
 Please repeat last order. (skip next series of questions)
 Please let me know if there is a volume discount for ordering a larger quantity (i.e. 6 months vs 1 year supply) Note: Most of our products we do offer a volume discount.
Name of Contact lens: 
  (if you wear more than one brand)
Colour of Contact lens: 
  (if applicable)
Which eye:*  Right eye
   Left eye
   Both eyes
Quantity:*  1 month (available only for daily lenses)
   3 months (available only in daily and bimonthly lenses)
   6 months
   1 year
   Same as last time
NOTE: You will receive an email confirmation that we have received your order. If you have not heard from us within 2 business days, please call our office.
We are happy to refill your contact lens order, but your eye health is ALWAYS our priority. Contact lens wearers require annual or bi-annual vision examinations, depending on their health history, to maintain optimal comfort, vision and eye health.
* Required Fields
Accepting new patients
throughout Waterloo Region
Top 10 Optometry Clinics in Waterloo
Congratulations to Dr. Monica Furniss and Associates on winning the 2015 Patients' Choice Awards for Optometrist in Waterloo, ON
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