HVC - Reorder Contacts

Helderman & Jacobs Vision Center
Reorder Contacts

"I really like your online contact lens reorder form. It offers a great convenience to your customers!"
-Katherine Bautista

IF YOU WANT TO ORDER REPLACEMENT CONTACTS YOU MUST MEET THESE REQUIREMENTS FIRST:

1. You must already be a patient at Helderman & Jacobs Vision Center.

2. You must have seen the doctor in the last 12 months for a contact lens exam.

3. You must only be replacing contact lenses that you currently are wearing.

Anyone who wishes to re-order contacts with an exam over one year, must either call our office or schedule an appointment online. Filling out this form does not guarantee order of contacts. You will be contacted by email or telephone if your order is or is not current, the amount you owe, or any other additional information regarding your contact lens order.

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This webpage was last updated on October 23, 2006

*Required Fields Contact Information
*First Name
*Last Name
*Home Address 1
Home Address 2
*City
*State
*ZIP Code
*Home Phone	()
Work Phone	()
Cell Phone	()
Email Address
*How would you like us to notify you of your order status?	Telephone	Email


Personal Information
*Date of Birth

Order Information
*Shipment Method	Pick-up at Helderman & Jacobs Vision Center - Mt. Sterling, KY
	Pick-up at Helderman & Jacobs Vision Center, PLLC - Stanton, KY
	Have Contacts Mailed to Above Address
	Contacts will not be mailed until payment is received. A total balance will be confirmed by telephone or email so you can send payment quickly. Credit cards can be accepted by telephone.
*Order Contacts for	Right Eye Only	Left Eye Only	Both Eyes

*Quantity of Lenses desired	1 box or lens	2 boxes or lenses	3+ boxes or lenses

Please add any comments you might have; (contact colors ect.). If you want us to bill an insurance for your contacts please state insurance information here.