Information Request Form

After completing the required information, press the submit button at the bottom of the form. A representative from our office will regular mail your request/s.
NOTE: You must be a resident of Colorado or an existing patient to utilize this service

Use the pull down menus to select the brochure information you desire

request 1
select one... Transition lenses Varilux lenses Ultra Litestyle lenses Crizal lenses TD2 lenses ----------------- Information on Soft Contact lenses Acuvue, Acuvue2, Acuvue bifocal contact lenses Fresh look contact lenses Wild eyes contact lenses Precision UV soft contact lenses Focus Dailies contact lenses ----------------- Ultraviolet Radiation Lacramedics for dry eyes

request 2
select one... Transition lenses Varilux lenses Ultra Litestyle lenses Crizal lenses TD2 lenses ----------------- Information on Soft Contact lenses Acuvue, Acuvue2, Acuvue bifocal contact lenses Fresh look contact lenses Wild eyes contact lenses Precision UV soft contact lenses Focus Dailies contact lenses ----------------- Ultraviolet Radiation Lacramedics for dry eyes

request 3
select one... Transition lenses Varilux lenses Ultra Litestyle lenses Crizal lenses TD2 lenses ----------------- Information on Soft Contact lenses Acuvue, Acuvue2, Acuvue bifocal contact lenses Fresh look contact lenses Wild eyes contact lenses Precision UV soft contact lenses Focus Dailies contact lenses ----------------- Ultraviolet Radiation Lacramedics for dry eyes

do you presently wear
contacts glasses both

when was your last eye exam
select one... within 3 months within 6 months within 12 months over 1 year

your name

address

city

state

zip

phone

email

how did you discover our website
select one... existing patient search engine yellow page ad other advertising

NOTE: All information submitted is kept confidential and is for our internal use only. All fields are required.