Contact Lens Form

Please fill out the form below. If you have never been seen in our clinic or if it’s been over a year since your last visit, please contact our clinic to schedule an appointment before filling out this form.

First Name (required)

Last Name (required)

Email (required)

Date of Birth (required)

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.

RIGHT LENS INFORMATION

Contact Lens Brand Name (Right eye) - REQUIRED

Base Curve (Right eye) - REQUIRED

Diameter (Right eye) - REQUIRED

Power (Right eye) - REQUIRED

Cylinder - Right Eye (For Toric Lenses ONLY)

Axis - Right Eye (For Toric Lenses ONLY)

Other- Right Eye (Example: Add Power, Color)

LEFT LENS INFORMATION

Contact Lens Brand Name (Left eye) - REQUIRED

Base Curve (Left eye) - REQUIRED

Diameter (Left eye) - REQUIRED

Power (Left eye) - REQUIRED

Cylinder - Left Eye (For Toric Lenses ONLY)

Axis - Left Eye (For Toric Lenses ONLY)

Other - Left Eye (Example: Add Power, Color)

Additional Lens Information

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.
Yes, please email my prescription to me.