GENERAL COMMENT AND/OR CONTACT LENSES ORDER FORM

NAME:
ADDRESS:
(Include street, city, state, zip)
EMAIL ADDRESS:
DAYTIME PHONE:
COMMENTS/ORDER:
If placing an order for contact lenses, please complete the following additional fields.
NUMBER OF BOXES:

PREFERRED
SHIPPING METHOD:


Email Dr. David!

Email Optical Department

Email Jill - Insurance/Billing

Email Carrie - Optometric Assistant and Receptionist

Call us at 660-707-0600. Fax us at 660- 707- 0611.

Physical Address:

883 Fairway
Chadwick Plaza
Chillicothe, MO 64601
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883 Fairway
Chadwick Plaza
Chillicothe, MO 64601

Phone: 660-707-0600
Fax: 660-707- 0611

Member Chillicothe Area Chamber of Commerce