Please fill out the order form below and our staff will contact you to confirm your order.

Please be aware, if your contact lens prescription is out of date, you will require an eye examination to renew the prescription.

First name*:
Last name*:
DOB*:
Contact number*:
Email:
RIGHT Eye:	Please select none Another lens type - please call me to arrange J&J Acuvue Oasys - 3 month supply J&J Acuvue Oasys Toric - 3 month supply J&J Acuvue One Day Moist - 1 month supply J&J Acuvue One Day Moist - 3 month supply ProBalance - 6 month supply Proclear - 6 month supply Proclear Multifocal - 6 month supply Proclear Toric - 6 month supply ProView Plus One Day lenses - 1 month supply ProView Plus One Day lenses - 3 month supply Purevision - 3 month supply Purevision - 6 month supply Purevision Multifocal - 6 month supply Purevision Toric - 3 month supply Purevision Toric - 6 month supply
LEFT Eye:	Please select none Another lens type - please call me to arrange J&J Acuvue Oasys - 3 month supply J&J Acuvue Oasys Toric - 3 month supply J&J Acuvue One Day Moist - 1 month supply J&J Acuvue One Day Moist - 3 month supply ProBalance - 6 month supply Proclear - 6 month supply Proclear Multifocal - 6 month supply Proclear Toric - 6 month supply ProView Plus One Day lenses - 1 month supply ProView Plus One Day lenses - 3 month supply Purevision - 3 month supply Purevision - 6 month supply Purevision Multifocal - 6 month supply Purevision Toric - 3 month supply Purevision Toric - 6 month supply
Solutions:	Please select none Blink eye drops 10mL Boston Advance Cleaning Solution - 30mL Boston Advance Condition Solution - 120mL Boston Advance Rewetting Solution - 10mL Boston Simplus Multipurpose Solution - 120mL Celluvisc single-use 30-pack Menicare Plus 120mL rigid lens solution Optifree multipurpose solution - 300ml bottle Optive eye drops - 10 mL Optive eye drops - 15 mL SteriLid - 48mL Systane - single-use 28-pack Systane - 15mL bottle TheraTears - single-use 24-Pack
Delivery:	Please select ---> I will collect from the Brisbane City office. Please post to me ($8.00 postage charge)
Notes: (please include postal address if you want the contacts posted to you)