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1-800-EYE-MATE

Register Your Rx

To register your contact lens prescription online, or for us to call to obtain your current contact lens prescription, please fill out the following form below.

There is absolutley no cost to register your prescription and you do not have to place an order at this time. We will e-mail you once your prescription is registered.

Your Name:
E-mail:
Street:
City:
State:
Zip Code: Country:
Telephone: Fax:
Doctor's Name:
Doctor's Phone:
Date of last visit:
Lens Manufacturer: 
                         Right (od)     Left (od)
 Power  ------------         
 Base Curve --------         
 Diameter ----------         

 For Toric lenses
 Cylinder ----------         
 Axis --------------
  I do not want to place an order at this time, but please register my Rx. at no cost to me.
  I want to place an order, register my Rx. immediately.
 
Comments:
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