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Contact Order Form
As a commitment to our patients, we now offer the convenience of ordering your contact lenses through our website.

Shoreline Vision has developed a safe and secure order form for our patients to use and can be assured their privacy is protected while making online purchases.

Please follow the instructions below to place your contact lens order:

1.Fill out the contact lens form completely
2.You will receive a confirmation email from an optician confirming the placement of your order
3.Upon approval your order will be available to pick up at the office or if you want to have it shipped to your home please choose the appropriate shipping method below
Secure Online Form! (all fields are required to process order correctly)


Patient Information:
Last Name First Name-- Middle Initial
Email------- Date of Birth
Address**:
Street **we are not able to ship to Post Office boxes
Street
City --- Telephone Number 1 ---
State- Zip Telephone Number 2 ---
Insurance Information:
Name of Insurance Company--
Member/guarantor: Last Name First Name -------Middle Initial
Member's Date of Birth-----------
Member's ID or Social Security Number
Contact Lens Order Details:
Type: Right Left Both
Product:
Number of Boxes:
Billing Information:
Name on Card:---
Credit Card Type: Credit Card Number:   (no dashes)
Expiration Date: --   (mmyy)
Please select a shipping method:
Comments:
Contacts Department 231-739-9009 Ext. 123

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