Kansas City Eye Clinic

Andrew Wang
Practice Administrator
913.341.3100
awang@kceyeclinic.com

To order contact lenses, please complete this order form. Standard shipping is free when you purchase a year's supply.

Name:

Address:

City:

State:

Zip

Phone:

Email:

Are a you a new or existing patient?:

New

Existing

Soft Disposable Orders

Left Eye:

# of multi-packs

Right Eye:

# of multi-packs

All Other Orders

Replacement Lens for Left Eye

Replacement Lens for Right Eye

Replacement Lens for Both

Shipping - Please Select One

Pick-up (You will be called when lenses arrive)

Regular Mail ($6.00)

Overnight (Add $20)

Credit Card Info

Your information will be submitted via a
secure site to protect your confidentiality.

Name on Card:

Billing Zip Code for Card:

Card Number: (numbers only)

Expiration Date:

mm/yy

Card Security Code:

(3 digit # on back of card by your signature)

Card Type:

Question/Comments:

Your information will be submitted via a
secure site to protect your confidentiality.

Your Vision Is Our Focus