Please complete this form and we will contact you within two business days to confirm your order. Fields with an * are mandatory. Location * - Select -265B Concession St.677 Innovation Dr. We now have 2 locations to serve you better. Our main clinic is still located at 265B Concession Street. Our satellite clinic is located in the east end of Kingston at 677 Innovation Drive, Unit 5, just off Highway 15. Number of months required * - Select -3612 Doctor * - Select -Dr. Rebecca ChippiorDr. Brandon StephensDr. Tiffany NazarethDr. Alexander YowakimDr. Samantha Chapman Title * - Select -MrMrsMissMsDr First Name * Surname * Telephone * Email * Preferred Method of Contact * - Select -EmailPhone Date of Birth Day * - Select -12345678910111213141516171819202122232425262728293031 Month * - Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year * - Select -19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Rebate Submission * No Yes Contact lens companies often offer rebates for patients who purchase their product. If your purchase is eligible for a rebate, would you like us to submit your rebate form as a convenience to you? Comments Leave any extra details if necessary.