Order Contacts

Home   Services   Eye Glasses   Contacts   LASIK   Appointments   Our Staff   Privacy Notice   Contact Us		This order form is for current Tyrone Eye Care patients only. Once we receive your request, we will then contact you to confirm your order, prescription info, and method of payment. We do not ask for any payment information on this form. After we receive your request, we will contact you by phone for your payment information. If this form does not fit your request or you would prefer to contact us by phone or fax instead - all of our contact information can be found here. Please review our Notice of Privacy Practices. Thank you. Contact Info Name: Phone:   Work   Home Fax:   E-mail: Address:  Line 1    Line 2   City     State   Zip Code Insurance:  Company Name  Policy Number  Phone Number Order Info How many boxes of contacts or lenses per eye? Left:      Right:  How would you like the contacts delivered? Ship contacts to your home address ($5.00) Pick up contacts from our office Comments:

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