Contact Lens Reorder – Online Form

- Step 1 of 3

Name *

First

Last

Are you an Existing Patient at Neilson Eyecare and already wear Contact Lenses *

• Yes
• No

Please do not proceed with this form and give our practice a Call - 07 4638 2377

Is your Contact Lens Prescription in date/valid? (contact lenses last 12 months) *

• Yes
• No
• Unsure

Please do not proceed with this form and give our practice a Call - 07 4638 2377

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Phone *

Email *

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What type of Contact Lenses do you Need? *- Please select -DailiesFortnightlyMonthliesOrtho K

Daily Contact Lenses

Right Eye Dailies

• Box of 30
• Box of 90

Left Eye Dailies

• Box of 30
• Box of 90

Fortnightly Contact Lenses

Right Eye Fortnightly

• Box of 30
• Box of 90

Left Eye Fortnightly

• Box of 30
• Box of 90

Monthly Contact Lenses

Right Eye Monthlies

• 3 Month Supply
• 6 Month Supply

Left Eye Monthlies

• 3 Month Supply
• 6 Month Supply

Ortho K

Ortho K Eye

• Right
• Left

How Many Boxes Right Eye?

How Many Boxes Left Eye?

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Contact Lens delivery *

• I will pick up my prescription
• Please post prescription to my address ( I understand there may be a charge for this)

Please add any delivery information here

Do you wish to Claim this on your Private Health Insurance? *

• Yes
• No

How would you like to pay? *

• In practice
• Over the phone
• Bank Transfer

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