Dr. Justin Gordon - Optometrist Chicago Illinois

To Reorder Contact Lenses

( We can only fill orders for existing patients)

Name:

Daytime Phone:

Email:

Optional Information (if you know it)

Type of lenses:

Brandname:

# of boxes needed:

( 2 boxes = 3 months; 4 boxes = 6 months)

Annually Replaced Lenses

Left Right

Regular or Color