The Tiffin Eye Center
      Changing the Way You See... and the Way Others See You.

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Surgical
Procedures
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Overview
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Notice
This page is for ordering contact lenses. To order them, you must
have a current contact lens prescription on file and be a patient
of ours.

We will send you a confirmation E-mail once the order is placed.

Fill out the following form and hit "Send" to e-mail it to us. If
you don't have all your prescription information on hand, we will
look up that information in our charts.

(Fields in Bold must be filled out.)
Patient Name:
Patient Address:
Suite/Mailstop:
City, State, Zip: ,     
Date of Birth:  /  /  
Lens Brand:
(ie. Acuvue, Focus)
Power:
Base Curve:
# of boxes:
Right Eye
# of boxes:
Left Eye
E-mail:
  

Surgical Procedures | Doctors | Services Overview
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