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Daily
---1-Day Acuvue Moist 30s1-Day Acuvue Moist 90s1-Day Acuvue Moist Astig 30sBiomedics 1 Day Toric 30sBiotrue One day 30sBiotrue One day 90sClarity 1 Day 30sDailies Aqua Comf MF 30sDailies Aqua Comf Plus 30sDailies Aqua Comf Plus 90sDailies Aqua Comf Toric 30sDailies Total 30sDailies Total 90sMy Day 30sProclear 1 Day 30sProclear 1 Day 90s

Weekly
---1 Day Acuvue TrueEyeAcuvue Oasys for AstigmatismAcuvue Oasys

Monthly
---Air Optix AquaAir Optix Aqua MultifocalAir Optix for AstigmatismBiofinityBiofinity MultifocalBiofinity ToricBiofinity Toric XRFrequency AsphericFrequency XCFrequency Xcel ToricProclear MultifocalProclear Multifocal ToricProclear SphereProclear ToricPurevision 2HDPurevision 2HD for AstigPurevision MultifocalPurevision ToricSoftlens Toric

How many boxes?
---1 Box2 Boxes3 Boxes4 Boxes5 Boxes6 Boxes7 Boxes8 Boxes9 Boxes10 Boxes

I am in possession of a valid prescription YesNo

Please note it may not be older than 12 months.

LEFT LENS

BaseCurve
---8.37.48.58.68.78.88.99.0

Sph
---+20.00+19.75+19.50+19.25+19.00+18.75+18.50+18.25+18.00+17.75+17.50+17.25+17.00+16.75+16.50+16.25+16.00+15.75+15.50+15.25+15.00+14.75+14.50+14.25+14.00+13.75+13.50+13.25+13.00+12.75+12.50+12.25+12.00+11.75+11.50+11.25+11.00+10.75+10.50+10.25+10.00+9.75+9.50+9.25+9.00+98.75+8.50+8.25+8.00+7.75+7.50+7.25+7.00+6.75+6.50+6.25+6.00+5.75+5.50+5.25+5.00+4.75+4.50+4.25+4.00+3.75+3.50+3.25+3.00+2.75+2.50+2.25+2.00+1.75+1.50+1.25+1.00+0.75+0.50+0.250.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00-10.25-10.50-10.75-11.00-11.25-11.50-11.75-12.00-12.25-12.50-12.75-13.00-13.25-13.50-13.75-14.00-14.25-14.50-14.75-15.00-15.25-15.50-15.75-16.00-16.25-16.50-16.75-17.00-17.25-17.50-17.75-18.00-18.25-18.50-18.75-19.00-19.25-19.50-19.75-20.00

Cyl
---0.00-0.25-0.75-1.25-1.75-2.25-2.75-3.25

Axis
---102030405060708090100110120130140150160170180

Add
---+1.00+1.25+1.50+1.75+2.00+2.25+2.50

RIGHT LENS

BaseCurve
---8.37.48.58.68.78.88.99.0

Sph
---+20.00+19.75+19.50+19.25+19.00+18.75+18.50+18.25+18.00+17.75+17.50+17.25+17.00+16.75+16.50+16.25+16.00+15.75+15.50+15.25+15.00+14.75+14.50+14.25+14.00+13.75+13.50+13.25+13.00+12.75+12.50+12.25+12.00+11.75+11.50+11.25+11.00+10.75+10.50+10.25+10.00+9.75+9.50+9.25+9.00+98.75+8.50+8.25+8.00+7.75+7.50+7.25+7.00+6.75+6.50+6.25+6.00+5.75+5.50+5.25+5.00+4.75+4.50+4.25+4.00+3.75+3.50+3.25+3.00+2.75+2.50+2.25+2.00+1.75+1.50+1.25+1.00+0.75+0.50+0.250.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00-10.25-10.50-10.75-11.00-11.25-11.50-11.75-12.00-12.25-12.50-12.75-13.00-13.25-13.50-13.75-14.00-14.25-14.50-14.75-15.00-15.25-15.50-15.75-16.00-16.25-16.50-16.75-17.00-17.25-17.50-17.75-18.00-18.25-18.50-18.75-19.00-19.25-19.50-19.75-20.00

Cyl
---0.00-0.25-0.75-1.25-1.75-2.25-2.75-3.25

Axis
---102030405060708090100110120130140150160170180

Add
---+1.00+1.25+1.50+1.75+2.00+2.25+2.50

How will you be paying for the contact lenses? Medical AidCash/Credit Card

Please attach a scanned copy of your prescription if you are not currently a patient of us.

Please attach a copy of your ID

Please attach a copy of your medical aid card