Patient Information

Name*

First Last

Email Address*

Phone Number*

SMS Consent

By checking this box, you agree to receive Customer Care messages from Couture Optical at the phone number provided above. You may reply STOP to opt-out at any time. For assistance, reply HELP. Message and data rates may apply. Message frequency will vary. Learn more on our Privacy Policy and Terms & Conditions.

You will receive an email letting you know when your contact lenses are ready for pick up.

Please check here if you would rather receive a phone call

Supply For

We will fill your order using your current prescription.
(You must have current contact lens prescription, within the past year)

Other Supply Needed:

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Additional Notes

Thanks for ordering your contact lenses through our website!

We look forward to seeing you soon!

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Patient Information

Couture Optical – 65th St

Couture Optical – 86th St