CONTACT LENS ORDER FORM
Check this box if you are an existing customer:
Title:
Surname:
Forename:
House No. And Street:
Town:
City/County:
Postcode:
Telephone:

e-mail address:

Right lens details

Left lens details

 

Colour(If "Freshlook " or "Colour Blend ")

 

Lens Type

 

Price per quantity required

Any other comments or information:

       

NOTE:

If you are currently not a patient with Chalmers Independent Opticians, contact lenses can only be supplied to an up to date specification from your own optician.

 

        
                         
  Chalmers Independent Opticians: 34 Albany Road Cardiff CF24 3RQ Telephone 02920 487375 Facsimile 02920 453969 e-mail mail@chalmersopticians.co.uk