UM Kellogg Eye Center at Ann Arbor
Contact Lens Order Form

If your prescription is on file at the Kellogg Eye Center at Ann Arbor and the prescription is less than a year old, you may re-order your contact lenses by supplying the following information.

You will be contacted regarding this order

- indicates a required field

Full Name:
Date of Birth:
UM Registration:
		Date of birth or UM Registration number is required
Contact Information:
Daytime Phone:		area code + number
Evening Phone:		area code + number
Email:
		Email me a copy of this order
I will pick up my order Ship my order to the address below * There will be a $7.00 shipping fee added to your order
Shipping Address:
Name
Address 1
Address 2
City
State		Michigan Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Contact Lens Order:
Lens Type:		Specify Lens Type Hard lens Soft lens
Number of boxes:
Payment Information
Office hours are 8:00 a.m. - 5:00 p.m., Monday through Friday. You will be contacted by a representative from the Contact Lens Clinic to verify your order and to obtain payment information. Payment is due at the time the order is processed. If you are not contacted within one (1) working day of placing your order, please call the Contact Lens Clinic at 734-936-8686.
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