Reorder Contacts

Contact Information:
Name *
Email Address *
Home Phone *
Mobile Phone
Notification*- When my order is ready to pick up, please notify me by Home Phone Mobile Phone Email
Insurance:
Do you have insurance?	Yes No
If yes, which one	Select One Vision Service Plan (VSP) Avesis Vision Care Direct Ameritas
Quantity: We will use your most recent contact lens prescription on file to fill your order. However, you must renew your contact lens prescription every 12 months with your doctor.
Patient Name*:	Number of boxes*:
Patient Name:	Number of boxes:
Patient Name:	Number of boxes:
Patient Name:	Number of boxes:
Patient Name:	Number of boxes:
Please enter the anti-spam code:

Please allow 24 hours for your order to be placed. You will receive an email confirmation when your order has been received. Please contact us at 402-563-3686 if you do not receive this confirmation notice.