Rebate Submission Form

Your Info:


Purchase Info:

  • Please upload original sales receipt showing proof of payment for your eligible contact lens purchase.
  • Purchase must be made within 60 days of eye exam.
  • Circle contact lens purchase and date on receipt.
  • All receipts must be from the same eye care practitioner who prescribed your contacts, or from a location affiliated with that practitioner.
  • Acceptable file formats: jpg, png, pdf.
  • Max file size 2 mb
Enter all qualifying UPCs purchased along with quantities. ***UPC required for valid claim***
* denotes required field