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Re-Order Contacts

To re-order contacts or for more information about our services, or any other questions or comments, please complete the form below.

Galiani Ophthalmology Associates
14-A Memorial Drive
Doylestown, PA 18901
Tel: 215.345.5144
Fax: 215.345.5846

Note: Do not use this form for an emergency!


* Name:
  
Address:
  
City:
  
Country:
  
* Phone:
  
Fax:
  
* E-Mail:
  
Order Information:
For non-disposable Contact Lens wearers:
I would like to order:
  
1 lens Right eye
   
2 lenses (both eyes) Left eye
For disposable Contact Lens wearers:
I would like to order:
  
Box(es) Right eye Box(es) Left eye
*Most brands package 6 lenses/box
Questions/Comments:
  
   
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