Eyewear Concepts - Dr. Melanie Oltmanns, O.D. & Dr. Nate Shilman, O.D.

  701-225-7886 |  800-942-1177
  448 21st St. W., Suite D-1
  Dickinson, ND 58601
  ndeyedr@aol.com

Contact Lens Order Form
*For Patients of Melanie Oltmanns, O.D., P.C./Eyewear Concepts only.

Patient Information
First Name		Last Name
Phone Number
Order Information
Right Eye Quantity, Box(es) or Vials
Left Eye Quantity, Box(es) or Vials
You will be contacted when your contact lenses arrive. Check here if you would like your contact lenses mailed directly to you. (Our office will contact you.)
If it is time for your yearly examination, or if your contact lens prescription has expired, our office will be in contact with you.
PAYMENT IS EXPECTED PRIOR TO CONTACT LENS DISPENSING.
Additional Comments or Questions: