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* All items marked with an asteris are required fields. failure to supply this information will delay your order.

* Your Name:

Mailing Address:

Company Name:

Email Address:

P.O. / Auth. By:

* Daytime Phone:

* O.D. / R:

(Right Eye)

Sphere:

Cylinder:

Axis:

Prism:

* O.S. / L:

(Left Eye)

Sphere:

Cylinder:

Axis:

Prism:

ADD

R:

L:

лл Bifocal Information, Complete only if you have Bifocal Prescription.

* Pupillary Width

Distance:

OR

Near:

OR

Distance Mono PD:

Example: 29/28

Segment Size

High:

Lens Type

Plastic

Polycarbonate

Glass

* Frame

Mfg:

Select Frame Aden On-Guard Titmus Techna

Style:

Color:

Eye Size:

Bridge Size:

Temple Length:

Side Shields

Permanent

Detachable

None

Tints

Velvet Lite (pink)

1

2

Contra Glare (green)

1

2

3

Coatings

UV

ASC

ARC

Vision Type

Single Vision

Flat Top

Trifocal (7x28)

Progressive

Double Segment

Kryptok

Other

Disclaimer

Acknowledge

Check Box To Confirm Patient Has Been Adivised Of Benefits And Detriments Of Each Type Of Lens.

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