Gothika® Theatrical Contact Lenses Order Form

Gothika® Theatrical Contact Lenses Order Form

You can order up to 10 styles and lens powers using this form. Note that stock lenses are available in powers from 0.00 to -6.00.
Practice Name*
Ordered By*

First NameLast Name
Account Number*
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com

Lens Order Details*

Note: Only lens styles marked with an asterisk (*) are available in Rx.

To order toric, scleral or hand-painted lenses, please call us at (866) 300-6257.
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