Instructions Please fill out the following form fields and submit the form to complete your order. If you are having trouble viewing or submitting the form please contact us at appts@eyedoctorsofdc.com
Date
Time
Patient’s Last Name
First Name
Middle Name
Home Phone Number
Work Phone Number
Cell Phone Number
Choose the method you wish to receive your lens order and fill out the appropriate information. Please choose only one method.
Washington DCVirginia
Street Address
City
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Zip Code
Number of Lenses 0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100
OR
Number of Boxes 0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100
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Last Name
Email Address
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