Contact Lens Form

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.

First Name (required)

Last Name (required)

Email (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.