ContactsLand.com Mail/Fax Order Form
If you wish to place an order by Mail or Fax: Print form, fill up clearly all
required fields and fax to
1-800-425-0283 or mail to ContactsLand.com, 10097
Cleary Blvd #235, Plantation FL 33324
| Name and Shipping Information | Billing Information (only if different -CC's) |
| Name:______________________________ Street Address:_______________________ ___________________________________ City:________________State___Zip______ Day Phone #______________________ Email Address:________________________ |
Name:______________________________ Street Address:_______________________ ___________________________________ City:________________State___Zip______ Day Phone #______________________ |
| Product Information and Prescription | ||
|
Eye (circle): Product Name - Description-Power/BC/Diam
|
Quantity: | Price: |
|
Right - Left ___________________________________________
Right - Left ___________________________________________ Right - Left ___________________________________________ Right - Left ___________________________________________ Shipping and Handling (US Only): Total: |
# _______ # _______ # _______ # _______ |
$ _______
$ _______ $ _______ $ _______ $5.95 _______ |
|
Prescription Information:
Name of the Doctor:_________________________________________ Doctor's/Office Phone No:___________________ Payment Method |