Dr Barnes - Midtown Eye Care

Please use our online form to re-order contacts for pick-up or delivery. Please be sure to respond to our verification email we will send you. No order will be processed until this is done. Thank you!

Patient Name*

First NameLast Name

Date of Birth

MonthDayYear

Phone Number

Area CodePhone Number

E-mail*

Boxes Needed for Right Eye

Right Eye Prescription

Boxes Needed for Left Eye

Left Eye Prescription

Name of Contacts*

Use Your Insurance?*

YesNo

Name of Insurance Company*

Policy Holder's Name*

First NameLast Name

Policy Holder's SSN*

Policy Holder's Date of Birth*

MonthDayYear

Your card will not be processed or charged until we verify a recent Eye Exam (less then 12 Months) and email you a total and receive your emailed approval. All credit card information is transferred from our secure page to our secure Email for your security. Your information will remain confidential. Please see our Privacy Statement for more information.

Credit Card Issuer*

Name on Card*

First NameLast Name

Card Number*

Expiration Date*

MonthDayYear

Delivery or Pick Up Order?*

I will pick them up at the office (Credit card required)Please deliver them to the address below

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Additional Notes, Questions or Concerns

Delivery is free for annual supply purchases, shipping/handling fees do apply for other orders.

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