West Vancouver Optometry Clinic

Please fill in all required fields below and we would be happy to refill your contact lenses. Contact lens wearers require annual health and contact lens evaluations to maintain optimal comfort, vision and health. If you are a West Vancouver Optometry patient whose exam was over 1 year ago, we will contact you after you submit this form to book your routine exam before filling this order. If you are not currently a patient, we encourage you to fill in all fields and we will contact you to arrange the necessary appointments.
Title:
First name*:
Last name*:
Date of birth*:
Day time telephone*:
E-mail*:	(for confirmation email only, will not be given to a third party)
Type of lenses required*:	Name of product:
	Right Eye Left Eye
	Quantity: 1 year 6 months Refill my last order
Comments:
Would you be interested in being kept informed of clinic promotions, offers or updates? Yes No