Contact Lens Order Form

Please complete the following and fax into our office at (928) 680-8639

CLIENT INFORMATION Date _____________

Name ____________________________________ Address ____________________________________

City ____________________________ State ___________ Zip _______ Phone_____________________

Work Phone ___________________ Place of Employment _____________________________________

Best Time/Place to Reach You ______________________________________ S.S.#_________________

E-Mail Address ________________________________________________________________________

*PAYMENT IS DUE PRIOR TO HAVASU EYE CENTER SHIPPING YOUR ORDER

Is billing address the same as the address listed above? Yes No

If no, what is the billing address? _____________________ City _______________ ST_____ Zip _______

Is the shipping address the same as the address listed above? Yes No

If no, what is the billing address? _____________________ City _______________ ST_____ Zip _______

How did you become aware of our clinic?

Drove by Yellow Pages Newspaper Business Expo/Show Welcome Wagon

Other __________________ Personal recommendation (Whom may we thank?) ___________________

Current Patient

Type of Contact

Brand of Contacts requested

Prescription strength

Color

Previous optometrist/ophthalmologist name & phone number. _____________________________________

Please indicate choice of payment: Cash/Check Visa Mastercard Discover

Credit Card Number _______________________________ Exp. Date ______________________________

Signature _______________________________________________________________________________

Havasu Eye Center s 383 Lake Havasu Ave Lake Havasu City, AZ 86403 Fax (928) 680-8639

www.havasueyecenter.com info@havasueyecenter.com