AC Lens Printed Order Form

CALL: 1-888-248-LENSFAX: 1-877-291-8154E-MAIL: sales@aclens.comMAIL: 4265 Diplomacy Drive Columbus, Ohio 43228 United States
Are you a previous customer? NO YES - Enter your last order number (optional):
Your Billing Information
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)
VisaMasterCardDiscoverAmerican ExpressCheck/Money OrderCard 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 / DescriptionEyePWRBCDIAPrice (each)QtyFinal Total
        
        
        
        
        
Subtotal: 
Sales Tax: 
Click Here to determine your shipping method and charge. Opens in a new tab 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 https://www.aclens.com/terms-and-conditions Open dialog and the Notice of Privacy Practices found at https://www.aclens.com/hipaa-notice Open dialog 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