Contact Lens Reorder Name *: Daytime Phone *: Evening Phone: Email *: DOB *: Referring Provider *: Select Provider Dr. Chang Dr. Zaffaroni Dr. Grewal Altos Optical Shop Referring Provider Phone *: Order Information *Fees Include Tax Select Right Lens Brand Acuvue 1-Day Define - 30 pack $50.00 Acuvue 1-Day Define - 90 pack $100.00 Acuvue 1-Day Moist - 30 pack $35.00 Acuvue 1-Day Moist - 90 pack $65.00 Acuvue 1-Day Moist for Astigmatism - 30 pack $40.00 Acuvue 1-Day Regular - 30 pack $35.00 Acuvue 1-Day Regular - 90 pack $65.00 Acuvue 1-Day Tru Eye - 90 pack $85.00 Acuvue 2 - 6 pack $25.00 Acuvue Oasys - 12 pack $70.00 Acuvue Oasys - 24 pack $130.00 Acuvue Oasys for Astigmatism - 6 pack $50.00 Acuvue Oasys for Presbyopia - 6 pack $60.00 Air Optix Aqua - 6 pack $50.00 Air Optix Aqua Colors - 6 pack-blue $90.00 Air Optix Aqua Colors - 6 pack-brilliant blue $90.00 Air Optix Aqua Colors - 6 pack-brown $90.00 Air Optix Aqua Colors - 6 pack-gemstone green $90.00 Air Optix Aqua Colors - 6 pack-gray $90.00 Air Optix Aqua Colors - 6 pack-green $90.00 Air Optix Aqua Colors - 6 pack-honey $90.00 Air Optix Aqua Colors - 6 pack-pure hazel $90.00 Air Optix Aqua Colors - 6 pack-sterling gray $90.00 Air Optix for Astigmatism - 6 pack $80.00 Air Optix Multifocal Aqua - 6 pack $90.00 Air Optix Night and Day - 6 pack $80.00 Alden HP 49 or 59 - 4 pack $150.00 Alden HP 49 or 59 Toric - 4 pack $200.00 Aquaflex STD (DW) - 1 pack $100.00 Avaira - 6 pack $35.00 Biofinity - 6 pack $60.00 Biofinity Multifocal - 6 pack $70.00 Biofinity Toric - 6 pack $80.00 Biomedics Premier/BioXC Aspheric - 6 pack $25.00 Biomedics Toric - 6 pack $50.00 Biotrue 1-Day - 90 pack $70.00 B&L Optima 38/SP - 2 pack $100.00 Clear Sight 1-Day Toric - 30 pack $50.00 Clear Sight 1-Day UV - 30 pack $30.00 Clear Sight 1-Day UV - 90 pack $60.00 Cvue 55 Toric Multifocal - 4 pack $180.00 Cvue Multifocal - 6 pack $60.00 Dailies Aqua Comfort Plus - 30 pack $30.00 Dailies Aqua Comfort Plus - 90 pack $65.00 Dailies Aqua Comfort Plus MF - 30 pack $40.00 Dailies Aqua Comfort Plus MF - 90 pack $110.00 Dailies Aqua Comfort Plus Toric - 30 pack $40.00 Dailies Aqua Comfort Plus Toric - 90 pack $90.00 Dailies Total 1 - 30 pack $40.00 Dailies Total 1 - 90 pack $95.00 Expressions (Coopervision) - 6 pack $60.00 Extreme H20 - 6 pack $25.00 Extreme H20 Toric - 6 pack $40.00 Focus Dailies Toric - 30 pack $30.00 Focus Dailies Toric - 30 pack $30.00 Focus Monthly Softcolors - 6 pack $80.00 Focus Monthly VT - 6 pack $50.00 Frequency 55 Aspheric (FW) - 6 pack $35.00 Frequency 55 EW - 6 pack $35.00 Frequency 55 Toric EW - 6 pack $80.00 Frequency 55 Toric XR (cyl above -2.25) - 6 pack $110.00 Freshlook 1-Day - 10 pack-blue $21.00 Freshlook 1-Day - 10 pack-gray $21.00 Freshlook 1-Day - 10 pack-green $21.00 Freshlook 1-Day - 10 pack-pure hazel $21.00 Freshlook Color Dimensions/Radiance - 6 pack-caribbean aqua $60.00 Freshlook Color Dimensions/Radiance - 6 pack-pacific blue $60.00 Freshlook Color Dimensions/Radiance - 6 pack-sea green $60.00 Horizon 38 (Westcon) DW - 1 pack $60.00 Hydrasoft Toric (DW/FW) - 1 pack $150.00 Hydrasoft Toric Options - 4 pack (1 single and 3 pack) $200.00 Hydrasoft XW Options - 4 pack $150.00 Kontur 55 DW - 1 pack $60.00 Kontur 55 Toric - 1 pack $150.00 Miru 1-Day - 30 pack $33.50 Miru 1-Day - 90 pack $72.00 Ocuflex 53 - 1 pack $60.00 Ocuflex 53 Toric - 1 pack $150.00 Ocuflex 53 (MTO above +10.00 DW) - 1 pack $100.00 Optima Toric - 1 pack $150.00 Preference DW/FW - 4 pack $75.00 Preference Toric DW - 4 pack $160.00 Preference Toric XR (cyl above -2.25) - 4 pack $160.00 Preferred 55 (Choice AB) - 6 pack $25.00 Proclear - 6 pack $45.00 Proclear 1-Day - 90 pack $80.00 Proclear EP - 6 pack $40.00 Proclear 1-Day Multifocal - 30 pack $40.00 Proclear 1-Day Multifocal - 90 pack $110.00 Proclear Multifocal - 6 pack $60.00 Proclear Multifocal Toric - 6 pack $150.00 Proclear Multifocal XR - 6 pack $120.00 Proclear Toric - 6 pack $70.00 Proclear Toric XR (cyl above -2.25) - 6 pack $90.00 Pure Vision - 6 pack $60.00 Pure Vision Multifocal - 6 pack $80.00 Pure Vision Toric - 6 pack $60.00 Pure Vision 2 for Astigmatism - 6 pack $80.00 Soflens 38 (Optima FW) - 6 pack $25.00 Soflens Daily Disposable - 90 pack $60.00 Soflens Multifocal - 6 pack $60.00 Soflens Toric (DW/FW) - 6 pack $50.00 Special Eyes 54 or 59 Sphere - 4 pack $130.00 Vertex Sphere EW - 6 pack $25.00 Vertex Toric - 6 pack $40.00 Vertex Toric XR (cyl above -2.25) - 6 pack $80.00 Wavetouch Toric - 4 pack $240.00 Select Left Lens Brand Acuvue 1-Day Define - 30 pack $50.00 Acuvue 1-Day Define - 90 pack $100.00 Acuvue 1-Day Moist - 30 pack $35.00 Acuvue 1-Day Moist - 90 pack $65.00 Acuvue 1-Day Moist for Astigmatism - 30 pack $40.00 Acuvue 1-Day Regular - 30 pack $35.00 Acuvue 1-Day Regular - 90 pack $65.00 Acuvue 1-Day Tru Eye - 90 pack $85.00 Acuvue 2 - 6 pack $25.00 Acuvue Oasys - 12 pack $70.00 Acuvue Oasys - 24 pack $130.00 Acuvue Oasys for Astigmatism - 6 pack $50.00 Acuvue Oasys for Presbyopia - 6 pack $60.00 Air Optix Aqua - 6 pack $50.00 Air Optix Aqua Colors - 6 pack-blue $90.00 Air Optix Aqua Colors - 6 pack-brilliant blue $90.00 Air Optix Aqua Colors - 6 pack-brown $90.00 Air Optix Aqua Colors - 6 pack-gemstone green $90.00 Air Optix Aqua Colors - 6 pack-gray $90.00 Air Optix Aqua Colors - 6 pack-green $90.00 Air Optix Aqua Colors - 6 pack-honey $90.00 Air Optix Aqua Colors - 6 pack-pure hazel $90.00 Air Optix Aqua Colors - 6 pack-sterling gray $90.00 Air Optix for Astigmatism - 6 pack $80.00 Air Optix Multifocal Aqua - 6 pack $90.00 Air Optix Night and Day - 6 pack $80.00 Alden HP 49 or 59 - 4 pack $150.00 Alden HP 49 or 59 Toric - 4 pack $200.00 Aquaflex STD (DW) - 1 pack $100.00 Avaira - 6 pack $35.00 Biofinity - 6 pack $60.00 Biofinity Multifocal - 6 pack $70.00 Biofinity Toric - 6 pack $80.00 Biomedics Premier/BioXC Aspheric - 6 pack $25.00 Biomedics Toric - 6 pack $50.00 Biotrue 1-Day - 90 pack $70.00 B&L Optima 38/SP - 2 pack $100.00 Clear Sight 1-Day Toric - 30 pack $50.00 Clear Sight 1-Day UV - 30 pack $30.00 Clear Sight 1-Day UV - 90 pack $60.00 Cvue 55 Toric Multifocal - 4 pack $180.00 Cvue Multifocal - 6 pack $60.00 Dailies Aqua Comfort Plus - 30 pack $30.00 Dailies Aqua Comfort Plus - 90 pack $65.00 Dailies Aqua Comfort Plus MF - 30 pack $40.00 Dailies Aqua Comfort Plus MF - 90 pack $110.00 Dailies Aqua Comfort Plus Toric - 30 pack $40.00 Dailies Aqua Comfort Plus Toric - 90 pack $90.00 Dailies Total 1 - 30 pack $40.00 Dailies Total 1 - 90 pack $95.00 Expressions (Coopervision) - 6 pack $60.00 Extreme H20 - 6 pack $25.00 Extreme H20 Toric - 6 pack $40.00 Focus Dailies Toric - 30 pack $30.00 Focus Dailies Toric - 30 pack $30.00 Focus Monthly Softcolors - 6 pack $80.00 Focus Monthly VT - 6 pack $50.00 Frequency 55 Aspheric (FW) - 6 pack $35.00 Frequency 55 EW - 6 pack $35.00 Frequency 55 Toric EW - 6 pack $80.00 Frequency 55 Toric XR (cyl above -2.25) - 6 pack $110.00 Freshlook 1-Day - 10 pack-blue $21.00 Freshlook 1-Day - 10 pack-gray $21.00 Freshlook 1-Day - 10 pack-green $21.00 Freshlook 1-Day - 10 pack-pure hazel $21.00 Freshlook Color Dimensions/Radiance - 6 pack-caribbean aqua $60.00 Freshlook Color Dimensions/Radiance - 6 pack-pacific blue $60.00 Freshlook Color Dimensions/Radiance - 6 pack-sea green $60.00 Horizon 38 (Westcon) DW - 1 pack $60.00 Hydrasoft Toric (DW/FW) - 1 pack $150.00 Hydrasoft Toric Options - 4 pack (1 single and 3 pack) $200.00 Hydrasoft XW Options - 4 pack $150.00 Kontur 55 DW - 1 pack $60.00 Kontur 55 Toric - 1 pack $150.00 Miru 1-Day - 30 pack $33.50 Miru 1-Day - 90 pack $72.00 Ocuflex 53 - 1 pack $60.00 Ocuflex 53 Toric - 1 pack $150.00 Ocuflex 53 (MTO above +10.00 DW) - 1 pack $100.00 Optima Toric - 1 pack $150.00 Preference DW/FW - 4 pack $75.00 Preference Toric DW - 4 pack $160.00 Preference Toric XR (cyl above -2.25) - 4 pack $160.00 Preferred 55 (Choice AB) - 6 pack $25.00 Proclear - 6 pack $45.00 Proclear 1-Day - 90 pack $80.00 Proclear EP - 6 pack $40.00 Proclear 1-Day Multifocal - 30 pack $40.00 Proclear 1-Day Multifocal - 90 pack $110.00 Proclear Multifocal - 6 pack $60.00 Proclear Multifocal Toric - 6 pack $150.00 Proclear Multifocal XR - 6 pack $120.00 Proclear Toric - 6 pack $70.00 Proclear Toric XR (cyl above -2.25) - 6 pack $90.00 Pure Vision - 6 pack $60.00 Pure Vision Multifocal - 6 pack $80.00 Pure Vision Toric - 6 pack $60.00 Pure Vision 2 for Astigmatism - 6 pack $80.00 Soflens 38 (Optima FW) - 6 pack $25.00 Soflens Daily Disposable - 90 pack $60.00 Soflens Multifocal - 6 pack $60.00 Soflens Toric (DW/FW) - 6 pack $50.00 Special Eyes 54 or 59 Sphere - 4 pack $130.00 Vertex Sphere EW - 6 pack $25.00 Vertex Toric - 6 pack $40.00 Vertex Toric XR (cyl above -2.25) - 6 pack $80.00 Wavetouch Toric - 4 pack $240.00 Right Lens B.C. *: Left Lens B.C. *: Right Lens DIA *: Left Lens DIA *: Right Lens Pack Quantity *: Select Quantity 0 1 2 3 4 5 6 7 8 9 10 Left Lens Pack Quantity *: Select Quantity 0 1 2 3 4 5 6 7 8 9 10 Right Lens Power *: Select Lens Power Sphere Cylinder Axis Left Lens Power *: Select Lens Power Sphere Cylinder Axis Payment and Billing Information Please fill out the necessary information affiliated with your payment type. 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