Order Contacts
Fill out this order form so we can evaluate your request. We will call you to confirm your payment method & order requirements. If you have any questions, please give us a call.
Full Name
Date of Birth (mm/dd/yyyy)
Phone (xxx-xxx-xxxx)
Email
Patient Status
Which eye(s) are you ordering contacts for

Vision Insurance Info (Optional)
Enter plan provider and your ID #
(Note: Medicaid does not cover contact lenses)
Notes



Office Hours
Mon
9:00 - 5:30
Tue
9:00 - 5:30
Wed
9:00 - 5:30
Thu
9:00 - 5:30
Fri
9:00 - 5:30
Sat
10:00 - 2:00
Sun
Closed
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13768 Roswell Ave.
Suite 208
Chino, CA 91710

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Call (909) 627-2020

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Dr. Shameem Khan Optometrist, Inc. 13768 Roswell Ave. Suite 208 Chino, CA 91710 Phone: (909) 627-2020

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