If you are not a Discover Vision Centers patient, please provide your prescribing doctors information. We may need to call and request a fax of your most recent contact lens exam.

Contact Lens Information

If you are a DVC patient and do not have your contact lens information with you, please check the box below. Otherwise, please enter your contact lens information in the spaces provided. This information can be obtained from your most recent prescription or current contact lens box.

DVC Patient: I do not have the information with me. Please look it up.

Quantity (#per box) Power (+/-) Base Curve (BC) Diameter (DIA) Right Eye (OD): 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 30 Other +8 +7 +6 +5 +4 +3 +2 +1 0 -1 -2 -3 -4 -5 -6 -7 -8 -9 -10 -11 -12 -13 -14 -15 -16 -17 -18 -19 -20 Other .00 .25 .50 .75 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 9.0 Other Left Eye (OS): 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 30 Other +8 +7 +6 +5 +4 +3 +2 +1 0 -1 -2 -3 -4 -5 -6 -7 -8 -9 -10 -11 -12 -13 -14 -15 -16 -17 -18 -19 -20 Other .00 .25 .50 .75 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 9.0 Other Other Brand Information: (Brand info example: Proclear Multifocal, 1yr supply) Questions and Comments:

Delivery Method Please select one of the following options:   I would like my contact lenses shipped to the above address.   I would like to pick up my contact lenses at Discover Vision.   Other.   Please Explain:     **Please Note: A member of our team will respond within 24 hours, or one business day, to verify, arrange payment and finalize your order. If you would like to have your lenses shipped, your order will not be processed until payment is received.