Brand Name Contacts - Printed Order Form

Brand Name Contacts Printed Order Form
CALL: 1-877-251-LENS	FAX: 1-877-251-0911	E-MAIL: customersservice@brandnamecontacts.com	MAIL: 4265 Diplomacy Dr, Columbus, OH 43228 US

Are you a previous customer? NO YES - Enter your last order number (optional):
Your Billing Information Please PRINT
First Name:	Last Name:
Street Address:
Street Address 2:
City:	State/Province:
Postal Code:	Country:
Primary Phone #:	Evening Phone #:
E-mail Address:
Your Shipping Information (if different than above)
First Name:	Last Name:
Street Address:
Street Address 2:
City:	State/Province:
Postal Code:	Country:

Your Payment Information (select a payment method below)


Visa		MasterCard		Discover		American Express		Check/Money Order		Card Number On-File

Credit Card Number (numbers only, no spaces or dashes)

Expiration Date

Name on Card (as it appears on card)

Your Order Information

Item Name / Description

Eye

PWR

DIA

CYL

ADD

Color

PD (D)

PD (N)

Price (each)

Qty

Final Total

Subtotal:

Sales Tax:

Click Here to determine your shipping method and charge. Shipping Method And Cost:

Order Total:

Your Prescription Information (please enter the Patient Name and Doctor Information below)

Please PRINT

Patient First Name:

Middle Initial:

Last Name:

Patient Date Of Birth (MM/DD/YYYY) (optional):

	My current prescription is on file with Brand Name Contacts.
	I am including a copy of my prescription with this order form.
	Please obtain my current prescription from my eye doctor, my doctor's information is provided below:

Doctor / Eyecare Provider Name:

Doctor / Eyecare Provider Phone:

I have read and agree to the Terms and Conditions found at http://www.brandnamecontacts.com/terms_popup.asp and the Notice of Privacy Practices found at http://www.brandnamecontacts.com/npp_popup.asp and I accept the above charge. (Your signature below is required.)

Signature:

Please double-check that your order is complete and legible, especially the shipping address and phone number. Not providing a phone number or e-mail address could result in the delayment or unfulfillment of your order.
Checks and Money Orders should be made payable to: Arlington Lens Supply