Fax Order Form
Contactsmall - J&J Acuvue 2 I herewith order:
Acuvue 2 Contacts

Contact lenses.

Fax: 1-801-218-0848
Left Eye
Right Eye
Qty of Boxes Qty of Boxes
Power Left Power Right
Diameter Diameter
Base Curve Base Curve
Total Price $ (is calculated for you)
Firstname:
Lastname:
Street:
City:
Country:
Postal Code: State:
Telephone: Email:
Payment: Shipment:  
Creditcard #: Expiration:
Name on Card:
Card ID Number: What is the Card ID?
Print Window:
Instructions: Please fill in all of the fields in the form above. Then print it off and send it to the number shown on top of the form.
You will receive a confirmation email, that doesn't contain any of your creditcard information.
Please note that none of the information you fill into this form will be electronically sumbitted!
You must print this page and fax it if you wish to place an order with Contactsmall.Com.