AC Lens Printed Order Form
CALL: 1-888-248-5367 FAX: 877-291-8154 E-MAIL: service@aclens.com MAIL: 4265 Diplomacy Dr, Columbus, OH 43228 US
Are you a previous customer? NO YES - Enter your last order number (optional):
Your Billing Information
Please PRINT
First Name: Last Name:
Street Address:
Street Address 2:
City: State/Province:
Postal Code: Country:
Primary Phone #: Evening Phone #:
E-mail Address:
Your Shipping Information (if different than above)
First Name: Last Name:
Street Address:
Street Address 2:
City: State/Province:
Postal Code: Country:

Your Payment Information (select a payment method below)
Visa MasterCard Discover American Express Check/Money Order Card Number On-File
                               
Credit Card Number (numbers only, no spaces or dashes)
   
-
   
Expiration Date
                                                                     
Name on Card (as it appears on card)

Your Order Information
Item Name / Description Eye PWR BC DIA CYL AX ADD Color PD (D) PD (N) Price (each) Qty Final Total
                           
                           
                           
                           
                           
Subtotal:  
Sales Tax:  
Click Here to determine your shipping method and charge. Shipping Method And Cost:  
Order Total:  

Your Prescription Information (please enter the Patient Name and Doctor Information below)
Please PRINT
Patient First Name: Middle Initial: Last Name:
Patient Date Of Birth (MM/DD/YYYY) (optional):
My current prescription is on file with AC Lens.
I am including a copy of my prescription with this order form.
Please obtain my current prescription from my eye doctor, my doctor's information is provided below:
Doctor / Eyecare Provider Name:
Doctor / Eyecare Provider Phone:

I have read and agree to the Terms and Conditions found at http://www.aclens.com/terms_popup.asp and the Notice of Privacy Practices found at http://www.aclens.com/npp_popup.asp and I accept the above charge. (Your signature below is required.)
Signature:
Please double-check that your order is complete and legible, especially the shipping address and phone number. Not providing a phone number or e-mail address could result in the delayment or unfulfillment of your order.
Checks and Money Orders should be made payable to: Arlington Lens Supply