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9 Patrick Street West
Wingham, ON
N0G 2W0
Phone:(519) 357-1282    Fax:(519) 357-4509
 
Contact Lens Reorder Form



Note: You must fill in all the required fields

First Name: 

Last Name: 

Email Address:

Daytime phone number(cellphone preferred):


Pick-up Options:           
Address:
Province/State:
City:
Postal/Zip:  
Country:

We will use your current prescription for the order.
You will be contacted if your current prescription is no longer valid.


Optometrist's name (Optional):  

Quantity:           


Additional Comments: (Optional)



Human test:

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