Beltline Vision Clinic

 
Serving Irving Texas

 
Contacts Order
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Irving Texas
Community
Disclaimer
HIPA Privacy
Contacts Order
Contact
 Dr. Brian Smith
Therapeutic Optometrist
 
  

Welcome to our automated contact lens order form. Based on our Customer suggestions and after much research, we have implemented this automated internet order form. If you have any suggestions or comments, we have left space at the bottom of this form for your input. Additionally, after clicking on the submit button at the end of the form, a confirmation page with your selections and comments will be displayed for your records. As a special request we would appreciate having your e-mail address for future mailing of our new revamped newsletter which can be delivered in an electronic format.

Thank you,

Dr. Brian Smith

Please allow 5-7 business days for your order to come in. If we have your contacts in stock we will let you know as soon as we receive the e-mail. If the contacts have to be ordered, we will call to confirm that we have received it and we will let you know an approximate day of arrival for the order.
 

1. Please provide the following Billing information:

Billing Information:
 
Name: 
First Name              Last Name
Address1:
Address2:
City:
State:
Postal Code:
Day Time Phone:
i.e., XXX-XXX-XXXX
Email Address:

2. Please provide the following Product information:

Type & Brand of Contacts:
 
Type       Hard Contacts        Soft Contacts
Brand of Contacts
Choose one form of delivery      Mail to Me ($4.00)   

       Will pick up at the Irving location

  

3. Please provide the following Credit Card information:

Credit Card Information:
 
Name as it appears on Credit Card:
Credit Card Expiration:           
Credit Card Type:
Card Number

4. Please provide the following Shipping information
 (if different than billing address):

Shipping Information:
 
Name:
Address:
City:
State:
Postal Code:
Day Time Phone:

5. Comments or Instructions are appreciated

Thank you for your on-line order. We appreciate your business and hope we

can continue to serve you always.

Dr. Smith and Staff

Copyright © 2001 VisionClinic. All rights reserved.
Revised: 03/30/08
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MdH GroupCopyright 2003

Last Modified : 03/30/08 11:33 AM