Contact Lenses Web Fax USA: (509) 471-3069 
Contact Lenses Ordering Form I am a member
Rx Specifications Right Eye (OD) Left Eye (OS)
1 Product Name
2 Color (Color lens only)
3 Power (Sphere) '+' or '-'
4 Base Curve
5 Diameter
6 Cylinder (Toric only)
7 Axis (Toric only)   º   º
8 Add Power (Bifocal only)
9 Quantity*   Boxes   Lenses
10 Price (as per on-line rate) $    $   
11 Subtotal: (row 9 x row 10) $    $   
12 Grand total: (sum of row 11) $   
*Note: If you wear disposable lenses, please enter the number of BOXES PER EYE, not the number of lenses.
Destination Method of Shipping Shipping Cost (USD)
United States Priority with Confirmation $5.95
Canada Xpress Post with Confirmation $6.50
International Registered Air Mail with Tracking and Insurance $16.95

Shipping Info
First Name: Last Name:
Address: Zip:
 
Phone: Email:

Billing Info
First Name: Last Name:
Address: Zip:
 
Phone: Email:

Payment Info
Name:
Type of Payment: Exp Date:
Credit Card #:

TOTAL AMOUNT: $ (Grand total: row 12 + Shipping cost)
*ContactLensesWeb is a contact lens replacement center. We can only sell you the contact lenses that have been prescribed by your eye care practitioner within the last year, and with which you are wearing successfully.