First Name *

Last Name *

Contact Number *

Additional Information

Contact lenses are deemed to be a medical device. I know and understand that I must have a valid contact lens prescription (not older than 12 months) from an Optometrist to order contact lenses from Eye Online
*

I Agree

Do you require a medical aid invoice?
*

YES


NO

Choose Yes if you want us to provide you with a medical aid invoice

Do you want us to contact your optometrist for your prescription?
*

YES


NO

We will only send you relevant product information and order reminders. No SPAM, promise!