ORDER CONTACTS FORM | Visual Eyes Optical

Contact Lens Order Form

If you’re an existing Visual Eyes patient, you can order your contacts right here, right now. Simply fill out the form below to request your contacts. Our office will process your order and follow up with an order confirmation.

First Name

Last Name

Phone

Street Address

Street Address Line 2

City

State

Postal / Zip code

Would you like to pick up in office or have the contacts shipped directly to your provided address?

Ship to address

Pickup at Visual Eyes

Insurance: If available, would you like us to apply your insurance allowance?

Yes, bill my insurance if the contact lens allowance is available

No, do NOT bill my insurance for my contact lens allowance

Other comments or requests

Thanks for ordering your contacts. Our office will process your order and follow up with an order confirmation.

CONVENIENT MIDTOWN LOCATION

Exams & Retail Store

Visual Eyes Optical

1104 S 76th Ave

Omaha, NE 68124

Contact Us

(402) 955-2020

Email Dr. Kyle

Hours

Mon - Fri: 9am to 5:30pm

Sat: 9am to 1pm

Closed Sundays

Quick Links

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