Full Name*Date of Birth (Month/Day/Year)*We use this to verify your fileContact Phone Number*Email Address* How much of a supply would you like to order?*example: 1 year, 6 months, 90 pairs, etcFor an additional $10.00 would you like your contacts mailed to your home or business address?*Yes, please mail my contacts. I am aware there is an additional $10.00 fee.No, I will pick my contacts up at your office.Please be advised that if choosing "yes" to having your contacts mailed, the order may take up to 7 business days from this contact request submission to arrive to your home or office.If choosing "yes" to having your contacts mailed, please type the address below of where you would like them delivered.* We will only ship orders within CanadaCredit Card InformationIf choosing "yes" to having your contacts mailed you can either include your credit card information for payment below or call our office directly at (403) 255-2826 during office hours to arrange for payment information.Credit Card Type*VISAMasterCardAmerican ExpressCredit Card No.*Expiration Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year*2016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046204720482049205020512052205320542055205620572058205920602061206220632064206520662067206820692070Special RequestPlease advise us if you have any special requests, such as if you would like e-mail notification to advise you your supply is ready for pick up, alternate contact information, etc.EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms. We use 256 bit encrypted channel along with extended SSL certificate on our website for most secure experience.