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• Contact Lens Refills

Contact Lens Refills

If you are a current customer of Bedford Eye Care Centre, you may use this form to order refills of your contact lenses.

Contact Lens Refill Order Form

For your convenience, you may complete and submit this form to reorder more of your contacts based on your latest prescription.  Payment will be due on pickup in our office.  An email confirmation will be sent to you as a reminder of your order.

We cannot re-order your contacts if your prescription has expired. Contact Lens prescriptions are valid for one year.  We will contact you to schedule an eye exam if your prescription has expired.

Customer Information

First Name *

This is an instruction note on this field.

Last Name *

Street Address *

City *

Province *

Postal Code *

Phone *

Email *

Date of Birth *

Order Information

Would you like to be contacted about saving an average of $70 on an annual supply of your contacts?

?

Yes, please contact me

Number of Boxes, Right Eye * none 1 2 3 4 5 6 7 8 9 10

Number of Boxes, Left * none 1 2 3 4 5 6 7 8 9 10

Brand *

How would you prefer to receive your contact lenses? * Please contact me when they are available for pickup Please ship them free of charge to my address (above)

Any additional Instructions?

Enter the letters you see:

?

Submit