Contact

PolyVue

3610 Ocean Ranch Blvd,

Oceanside, CA 92056

Phone. 877-734-2010

Fax. 760-754-2022

International Sales

international@polyvue.com

Order Form

Note: PolyVue does not sell products directly to patients. Please contact your eye care professional.

Account #

Phone

Area Code

Phone First 3

Phone Last 4

Email

Contact Name

Patient Name

First Name

Last Name

OD - Product Type

Lens Power

Cylinder (if Toric)

Axis (if Toric)

Choose One:

Box

Trial

Quantity

OS - Product Type

Lens Power

Cylinder (if Toric)

Axis (if Toric)

Choose One:

Box

Trial

Quantity

If Stock lenses for fitting kit replenishment, provide the list of powers needed below:

Additional Message

Submit

We Look Forward To Hearing From You.

Office Hours

Monday-Friday 8AM-5PM PST

Note: PolyVue does not sell products directly to patients.