Cls Price Request

Contact Lens Price Request
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
How you would like to receive your pricing? *

Electronically (emailed) Text to cell phone
Email Address *
example@example.com
Phone Number *

Area Code Phone Number
Contact Lens Brand *
If other, please list:
Supply Requested
(90 days, 6 months, 1 year, etc.)
Rebate Disclaimer:

Wallingford Eye Care Center offers exclusive manufacturer rebates on contact lenses; these are only available for orders placed within 90 days of your contact lens fitting. If you are an existing patient, we will we will include rebate info (if applicable) based on the date of your last prescription. However, if this information is not available - such as if you have an outside prescription - please be aware that certain rebates may not apply.

Contact Lens Prescriptions:

Contact lens prescriptions issued by this practice are valid for one year from the date of your exam. If your Rx is expired, we will contact you to schedule an exam. If you have an outside prescription, you can use it to order contacts anytime before the expiration date.
Should be Empty:

Contact Lens Price Request