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Contact Lens Order Request Form

* Required






Phone
Email

I am a current FVC patient
Please verify my contact lens RX from:



Note: Most 12 month supplies have rebates. A contact lens technician will gladly check qualifying rebates for your purchase.


Yes
No
Unsure

A contact lens technician will call/email for payment arrangements.


Eyewear lines currently available at Family Vision Clinic:

  • Ete~
  • Flair
  • LaFont
  • Cazal
  • Italee
  • Christian Dior
  • Juicy Couture
  • Jimmy Choo
  • Kate Spade
  • CK
  • Jaguar
  • Nike
  • Carerra
  • OGI
  • Seraphin
  • Giorgio Armani
  • Calvin Klein
  • Gunnar
  • Maui Jim
  • Menizzi
  • Nine West
  • Wiley X
  • Bolle
  • Serengeti
  • Ray Ban
  • Visuelle by FVC
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