This form is for informational purposes only, and is not for ordering contact lenses. Please also note that email is inherently not secure and the data you are sending will not be encrypted. By submitting this form you are doing so at your own risk with the knowledge that this transmission of data is not encrypted.

Please report all parameters for both the right and left eye.

    Form Notes:
    Copy all numbers from your contact lens box exactly. Include the + and - symbols. If a value is 0.00 you do not need to add a symbol.



    Would you like us to email your contact lens prescription to you? By clicking the box below you are consenting to have your contact lens prescription emailed to you.