Michiana Eye Center & Facial Plastic Surgery

Replacement Contact Lenses

Patient Information:

Last Name	First Name	MI

Address Line 1

Address Line 2

City	State	Zipcode

Phone Number	Date of Birth	Email


Order Information:

Right Eye (# of boxes)	Left Eye (# of boxes)


Delivery Information (click one):

1) Call me when my contacts are ready. I will pick them up
2) Please mail my contacts UPS and charge me $8 additional
3) Please overnight my lenses so I receive them ASAP and charge me $15 (Rigid gas permeables and made-to-order lenses must be manufactured prior to overnighting, which can take 2-14 days)

Payment:

If you are requesting us to ship the lenses to you, we need payment prior to mailing. We accept credit or debit cards. Please click on the appropriate selection:
1) I authorize you to charge my credit/debit card on file
2) I will call your office and give you my credit/debit card information
3) I will provide my credit/debit card information and authorize Michiana Eye Center & Facial Plastic Surgery to charge my card accordingly.

Credit/Debit Card Information:

1) (choose one)	Credit	Debit
2) Card Type	American Express	MasterCard
	Visa	Discover
3) Card Number & Expiration Date
Number
Expiration
	Month Year

Special Instructions / Patient Comments:

If there's anything you'd like us to know, please do so below:

Design by Lucem Solutions