PLEASE SUPPLY SCHEDULED REPLACEMENT LENS / LENSES THE SAME AS:

ALTERNATIVELY SUPPLY THE FOLLOWING INFORMATION:

I AGREE THE ABOVE CONTACT LENSES HAVE BEEN WORN BY THE PATIENT AND NO ADVERSE CLINICAL REACTIONS HAVE BEEN REPORTED AND THE CONTACT LENSES PERFORMED AS INTENDED. *

REPLACEMENT LENSES ARE REQUIRED BECAUSE:

NB. YOU WILL GET A CONFIRMATION MESSAGE ON THIS SCREEN AND AN EMAIL WHEN PROCESSED, THANK YOU FOR YOUR ORDER.
BY CLICKING SEND ORDER YOU ARE ORDERING THE REQUESTED PRODUCT AND AGREE TO THE TERMS AND CONDITIONS OF THE SALE.

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