First Name:

Last Name:

Address:

City:

State:

Zip:

Phone:

Fax:

e-mail Address:

I would like to order 1 2 3 4 5 6 7 8 9 10 pairs boxes of 1- Day Disposable 2-Week Disposable 1-Month Disposable Gas Permeable

The brand I use is

Please mail these to me (Shipping: $5.95 or FREE with annual supply)

I will pick these up at your Downtown Racine Office

Please use my credit card on file
I will call your office with my credit card info

You have my prescription info
My prescription is at another doctor's office,