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Contact Lens Order Form

This service is only available to current Dr’s. Bettio, Malchuk & Associates contact lens patients.

For those who have not purchased contact lenses from Dr’s. Bettio, Malchuk & Associates, click here.

If you have purchased contact lenses from us before, and would like a refill of your prescription, fill out the following form and we will contact you when the lenses arrive for telephone authorization of credit card payment.

Contact Lens Order Form

Name *

Home Phone *

Day Phone

Email *

Supply Needed *
 1 Month 3 Month 6 Month 1 Year Other (Please Specify in "Additional Comments" below)

How would you like to receive this order? *
 Pick-up from Store location Ship to the Address below *

Shipping Address

* Please note that an addition charge of $5-$20 may apply for shipping.

Additional Comments

  • Most orders will be ready in 3 business days or less.