GO2CONTACTS.COM Order Form

Order Form:

If you prefer to fax: Fill out form, Print it out, Fax toll-free to 1-877-LENS 888
For International clients fax 001-604-433-5699

Please fill in the spaces completely, otherwise we will be unable to process your order.

Name:

E-mail: (required)

Address:

City:

State:

Zip:

Country:

Phone:

This order form is secure. But if you want you can submit this form without your credit card number
and call 1-800-892-3122 and leave your VISA, MC, or AMEX number on our voice mail.

VISA/Mastercard/AMEX Number:

Exp. Date:

    
Choose the lenses you want:

We'll need the following info to correctly process your order. You'll find it on your contact lens Rx that you received from your optometrist. If there is a blank you do not know how to fill out it's ok. We'll e-mail you back if we require that information.

	Left Eye(OS) Right Eye(OD)
Quantity:
For disposables (eg. Acuvue, Biomedics...) quantity is number of boxes.
Power:		Usually a number between +8.00 and -12.00
Base Curve(BC):		Usually a number between 8.3 and 9.2
Diameter:		Usually a number between 13.0 and 14.8
Cylinder:		FOR TORIC LENS ONLY
Axis:		FOR TORIC LENS ONLY

      Please re-enter the TOTAL number of boxes :

Doctors Name:
Doctors Phone Number:

Comments? If placing multiple orders please put information below.
* Have you ordered before?-
* Please indicate which search engine was used to find our website- thank you

* If you are referred by a friend, please fill in their e-mail address or the "Give $5 - Get $5" promo number (4 digits).

Name:
E-mail:	(required)
Address:
City:
State:
Zip:

Country:
Phone:
This order form is secure. But if you want you can submit this form without your credit card number and call 1-800-892-3122 and leave your VISA, MC, or AMEX number on our voice mail.
VISA/Mastercard/AMEX Number:
Exp. Date: