Contact Lens Ordering

Lexington Eye Associates, Inc.
Contact Lens Order Form

Last Name:

First Name:

Middle I:

Street Address:

City/Town:

State:

Zip:

DOB:

(MM/DD/YY)

Telephone No.:

(Please Include Area Code)

E-Mail:

TYPE OF LENS:

How many boxes/lenses required:

Right Eye		Left Eye

Other: Please explain in the following space.

TO PICK UP YOUR LENSES:

We will notify you via e-mail when your lenses are in. Check one location below.

	Lexington - 21 Worthen Road
	Concord - John Cuming Bldg, 131 ORNAC - 3rd Floor
	Arlington - 281 Mass. Ave.
	Westford - 133 Littleton Road, Suite 204

I prefer to have my lenses sent to me via US Mail (Shipping cost applies)

We will notify you via e-mail when we send your order.