VisionmannOptometrists

Contact Lens Prescription Order Form
Complete and submit the following online form and we will respond
by email with a price by the end of the next business day.
OR
print this form & fax it to 281-298-2072

Overnight delivery service is available from many manufacturers. Call
281-298-2020 or email for details.
Patient Name:

Patient Address:

Patient Phone:
Date of Birth:

Prescription Date:

Expiration Date:
LENS
BC
DIAM
POWER
COLOUR
QTY
OTHER
OD
OS
Replacement Interval:
Wearing Schedule:
Disinfection/Cleaning: 		Prescribing Doctor's Name:

Prescribing Doctor's Phone:
Patient Email Address:
Notice to Patient: Contact lenses are medical devices that can only be dispensed by prescription. They must be regarded with the same caution you would use for prescription drugs, including expiry dates and follow-on visits. Contact lens prescriptions can only be filled by a licensed optometrist, medical doctor, pharmacist or an optician holding a contact lens dispensing permit from the Texas Department of Health. Dispensers who fill expired prescriptions, dispense more lenses than authorized or otherwise improperly fill prescriptions are subject to a $1000.00 fine per lens and/or suspension or revocation of their license or permit. Report all violations to Texas Department of Health hotline at 1-800-542-5540.