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Contact Lens ℞ Verification

Verification

First name*

Last name*

Date of Birth*

Month

Day

Year

Phone*

Email*

Address*

Prescriber Name*

Office / Clinic Name*

Office / Clinic Phone*

Office / Clinic Email

Issue Date*

Expiration Date*

Lens Brand*

Power (Sphere)*

Base Curve*

Diameter*

Add Cylinder / Prism (if applicable)

Prescription Upload*

Please upload a copy of your prescription for our records. (Accepted file types include .pdf, .jpg, .png)

Any notes provided by prescriber

I understand the potential risks from wearing contact lenses and understand that, by law, Haus of Electric Love cannot fulfill contact lens orders without a valid prescription, as required under Texas and Federal law.

I authorize Haus of Electric Love to contact my prescriber to verify my prescription.

Visit the Haus

321 W 19th Street, Suite A
Houston, Texas 77008

Monday: Closed
Tuesday-Thursday: 10am-7pm
Friday-Saturday: 10am-9pm
Sunday: 10am-6pm

Spread the Good Weird

RX VERIFICATION

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