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We will respect and protect your privacy! Eye Care Eye Wear Associates treats any information you submit as confidential and only uses it for the purposes of fulfilling your request. Eye Care Eye Wear Associates does not share your information with any third parties.

Your Information

In order for us to help you receive your contacts in a timely fashion. Please fill in the following form fields as accurately as possible.

Full Name (required)

Telephone (required)

Email (required)

Date of Birth: (required)

Your Street Address: (required)

Your Mailing Address: (required)


Order Information

Clinic: (required)

Number of Boxes:

  Left Eye:

Right Eye:


Anti-Spam Quiz:


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