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Reorder Contacts


Please fill out the following form to re-order contact lenses. Required fields are marked with asterisks (*).


The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

We must have a valid prescription for you on file. If we do not, please make an appointment with us for an eye exam.


About You

Patient Name: *

Home Phone: *

Cell Phone: *

Email Address: *

How do you prefer to be contacted? *

  Email    Phone  

Have you visited our office before? *

Yes  No  


Your Order

Orders will be evenly split between right and left eyes unless otherwise indicated.

Click here to see our price list. For rigid gas permeable lenses or for soft contact lenses not listed, please call our office at (503) 722-7737 .


Quantity Being Ordered

Right eye:



Left eye:



Any additional information:


Shipping Information

Shipping rates: $8.00 in-state, $10.00 out of state.
Free shipping when ordering an annual supply.


Please select a shipping option: *

I will pick up the lenses at the office
Ship to the address below (shipping fee may apply)


Shipping address (if order is to be shipped to you)

Street Address:





Payment by Credit Card

Full payment is required at this time. Any applicable rebates will be mailed to you.


Total Order Amount ($): *

Credit Card Number: *

Name on Card: *

Expiration Date: *

Verification Code: Help *


I have filled out this form as accurately and as complete as possible. *


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Telephone: 503-722-7737     22400 South Salamo Road, Suite 100     West Linn, OR 97068     Notice of Privacy Practices

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