Please fill out the following form completely

** NOTE: You must have a current prescription with Vogue Optical. First-time buyers please arrange an eye exam by calling 1-877-489-2020 or use our online form.

How many boxes of LEFT and RIGHT lenses do you wish to order?

#Left A value is required.Invalid format.       #Right A value is required.Invalid format.

Store Location
Select Store -- ---------------------- PRINCE EDWARD ISLAND -- Alberton -- Charlottetown, BrackleyPt Rd -- Charlottetown, ConfedCrt Mall -- Montague -- Summerside ---------------------- NEW BRUNSWICK -- Bathurst -- Dieppe -- Douglastown -- Florenceville -- Fredericton, KingSt -- Fredericton, MainSt -- Grand Falls -- Rothesay -- Hampton -- Miramichi -- Moncton -- Riverview -- Saint John, FairvilleBlvd -- Saint John, CharlotteSt -- Saint John, WestmorPlace -- Shediac -- Sussex -- St Stephen -- Oromocto -- Woodstock ---------------------- NOVA SCOTIA -- Amherst -- Bridgewater -- Dartmouth -- Glace Bay -- Halifax, BarringtonSt -- Halifax, QuinpoolRd -- Halifax, YoungSt -- Halifax, Kearney Lake -- Lower Sackville -- New Glasgow -- New Minas -- Sydney, MayFlower -- Sydney, PrinceSt -- Port Hawkesbury -- Truro -- Yarmouth -- Elmsdale ---------------------- NEWFOUNDLAND LABRADOR -- Clarenville -- Conception Bay -- Corner Brook -- Gander -- Labrador City -- Mount Pearl -- St Johns, DuckworthSt -- St Johns, KenmountRd -- St Johns, NewfoundlandDr -- St Johns Churchill Square -- Stephenville ---------------------- SASKATCHEWAN -- Saskatoon, 2nd Ave -- Saskatoon, 8th St
Please select a store.

Special Instructions
A value is required.

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First Name

Name or initial required.


Last Name

Last name is required.


City/Town

Town or city is required.


Address

Please provide address.


Province
-- Choose one -- Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador NW Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Please select a province.

Postal Code

Please include your postal code.


Phone 1

A value is required.


Phone 2


Email

Email is required.

Invalid format.

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Name on card

Name on card is required.

Card Type
-- Choose one -- Visa MasterCard
Please select a card type.

Card #

A number is required.
Invalid format.

Security Code (CVV2#)

Security number is required.
Invalid format.

Expiry Date

Month -- 1 2 3 4 5 6 7 8 9 10 11 12

Please select your card expiry month.

Year  

Card expiry year is required.
Invalid format.

Shipping

Please Ship   
I will pick up    

A $5.00 shipping charge will apply for shipped lenses.

*additional shipping charges may apply. You will be contacted if this applies to you.

 

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