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Order Contacts
Fill out this order form so we can evaluate your request. We will call you to confirm your payment method & order requirements. If you have any questions, please give us a call.

Office
Full Name
Date of Birth (mm/dd/yyyy)
Phone (xxx-xxx-xxxx)
Email
Patient Status
Which eye(s) are you ordering contacts for

Vision Insurance Info (Optional)
Enter plan provider and your ID #
(Note: Medicaid does not cover contact lenses)
Notes
Enter Letters/Number you see:



OFFICE HOURS    
Mon
8:00 - 5:00
Tue
8:00 - 5:00
Wed
8:00 - 5:00
Thu
8:00 - 5:00
Fri
8:00 - 5:00
Sat
8:00 - 1:00
Sun
Closed
2415 Homer Adams Parkway
Alton, IL 62002
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(618) 465-1712
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Heitz Optical - Alton 2415 Homer Adams Pkwy. Alton, IL 62002 Phone: (618) 465-1712 Fax: (618) 465-3114
Heitz Optical - Jerseyville 103 N State St Jerseyville, IL 62052 Phone: (618) 498-2060

Heitz Optical proudly serves Alton, IL and the surrounding areas of Godfrey, Bethalto, Rosewood Heights, East Alton, Hartford, Roxana, Brighton and Wood River.

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