Boston Eye Group – Boston Laser

Order Contact Lenses w/ Insurance

Your most recent contact lens prescription on file will be used for this order unless you specify otherwise in the comment section.
Submission of this form will not charge your credit card. You will receive a price quote from our contact lens department within 24 hours (Mon - Fri) after we contact your insurance.

Patient Name*
First Last
Email*
Phone*
Insurance Carrier*
Insurance ID#*
Quantity*
Other Quantity*
Credit Card Number*
Expiration Date*
Name on Card*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Choose Shipping Method*
Standard Shipping & Handling (SH/H) usually arrives in 3-5 business days, though this may vary if the Prescription (Rx) is out of stock. Some high Rxs may take 2-3 wks to arrive.
Shipping Address*
Click here if same as billing

Street Address Address Line 2 City State ZIP Code
Post Title