Norfolk Family Eyecare - Contact Lens Reorder Form
Please reorder your contact lenses through our website.
Our office may contact you:
1. To schedule a routine eye health exam or contact lens exam if you are due.
2. To discuss payment options as we do require a deposit to process the order.
Dr. Jane Van Dyk
Dr. Matthew Craig
Dr. Katie Ryan
3 month supply of daily disposable contact lenses
6 month supply of contact lenses
12 month supply of contact lenses
A different supply of contact lenses (specify supply below)
Do you need solution?
What brand of contact lens solution do you use?
Pick up/Delivery Options
I will come to the office to pick up.
Please ship to my office address (shipping fee may apply).
Please ship to my home address (shipping fee may apply).
Shipping address if different from home address.
Additional Comments/Special Requests
Do Not Fill This Out