Prism Optical - Online Eyewear Store

You Are Here: Shop Online -- Brand Air Optix Aqua --> Customer Information

PLEASE ENTER PRESCRIPTION AND CUSTOMER INFORMATION

I have ordered from you before.

Use prescription on file

I will fax a copy of my prescription to (800)-617-5367 or will email a scanned copy to contact@prismoptical.com.

Please use my prescription information below.

Please enter your prescription information below which must be verified by us before we can fill your order.

Below is my doctor's information so you can verify my prescription.
Doctor's Name:
Phone Number:	Ex: 555-555-5555
Practice Name:
City:
State:

Date of birth of the person who the order is for.

(mm/dd/yy)

Note any credits, warranties, etc. or any other information regarding your order.

Order Information
Contact Lens Price:	$42.00 Per Box

Please enter the quantity of boxes for both eyes. (Quantity is required)

Right:

Left:

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You Are Here: Shop Online -- Brand Air Optix Aqua --> Customer Information