Visioncare Arkansas - Eyewear and Eye Care

ALL ORDERS PLACED ARE FINAL
On-Line Ordering Information
Patient Information
Patient Name:	*
Date of Birth:	(01/01/1990) *
Phone Number:
Home/Cell:	123-123-1234 *
Work:	123-123-1234 *
E-Mail Address:	*
Payment Method
(please check one):	*
Card Number:	*
Card Name Holder:	*
Expiration Date:	mm/yyyy *
Shipping Information:
Shipping Method:	*
Name:	*
Street Address:	*
City:	*
State:	*
Zip:	*
A $8.95 shipping charge will be added to all orders under a 1 year supply and shipped directly to you.
Order Information:
How many boxes would you like to order?		Right Eye	Left Eye
PLEASE NOTE If you are wearing disposable contact lenses, please enter the number of boxes per eye you wish to order. The number of boxes cannot exceed a one year supply. All conventional contact lens wearers, enter the number “1” for each eye.
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