DATE WANTEDACCOUNT#  CONTACT PERSON

PATIENT NAME E-MAIL ADDRESS     

 SPECIAL INSTRUCTIONS:

   POLISHED EDGE    SELECT ONE     NO POLISH EDGE     POLISHED EDGES     ROLL AND POLISH EDGES       UV DYE   UNCUT   EDGED 

    COLOR or TINT     SELECT ONE     CLEAR     COSMETIC TINT{USE NEXT BOX}}     TRANSITIONS     COLORMATIC     SUNGRAY4     POLARIZED GRAY A     POLARIZED GRAY C     POLARIZED BROWN A     POLARIZED BROWN C     PGX     PBX     THIN AND DARK     OTHER {SEE BOX)    OTHER COLOR

    HARD COATING     SELECT ONE     NO     SRC FRONT     SRC FRONT AND BACK     BAR9 FRONT AND BACK (BEST)     OTHER {SPECIAL INSTRUCTIONS}    

    ANTI-REFLECTIVE COAT     SELECT ONE     NO AR COATING     TRANSPARENCE     MULTIQUARTZ     ZEISS BLUE     ZEISS GOLD     ZEISS COOL BLUE     SERENGETTI     OTHER {SPECIAL INSTRUCTIONS}  

    LENS MATERIAL     SELECT ONE     CR 39 PLASTIC     1.53 PHOENIX (TRILOGY)     1.54 SPECTRALITE     1.55-57 MID INDEX PLASTIC     1.58 POLY     1.60 HI INDEX PLASTIC     1.60 HOYA PLASTIC     1.66 HI INDEX PLASTIC     1.71 HOYA TESALID PLASTIC     1.53 CROW GLASS FDA HARDENED     1.53 CROWM GLASS NO HARDENED     1.60 GLASS FDA HARDENED     1.60 GLASS NO HARDENED     1.70 GLASS FDA HARDENED     1.70 GLASS NO HARDENED     1.80 GLASS FDA HARDENED     1.80 NO HARDENED     1.90 HI INDEX GLASS     OTHER {SPECIAL INSTRUCIONS}  THICKNESS     SELECT ONE     THIN AS POSSIBLE     1.0 MM     1.5 MM     2.2 MM     3.0 INDUSTRIAL  

    LENS STYLE       SELECT ONE     SINGLE VISION SPHERICAL     SINGLE VISION ASPHERIC     ST 28 SPHERICAL     ST 28 ASPHERIC     ST 25     ST35 SPHERICAL     ST 45 SPHERICAL     ROUND SEG 22 SPHERICAL     EXECUTIVE BIFOCAL     ULTEX BIFOCAL     7 X 25 TRIFOCAL     7 X 28 TRIFOCAL     7 X 35 TRIFOCAL     8 X 35 TRIFOCAL     PROGRESSIVE     OTHER {SPECIAL INSTRUCIONS}      SELECT PROGRESSIVE STYLE     AO FORCE     AO COMPACT     AO OMNI     AO TRUEVISION     HOYA GP     HOYA WIDE     KBCO FUSION     KBCO SOLARIS     NSL VANTAGE     OP NATURAL SIGHT     PEXTAX AF     PENTAX AF MINI     ROD LIFEC     ROD LIFE 2     ROD MULTRIGRESSIVE 2     ROD OFFICE     SA ELEGANCE     SA KODAK     SA NAVIGATOR     SI ADAPTOR     SI NATURAL     SI SUPER NO LINE     SO ACCESS     SO CONTINUM     SO PERCEPTA     SO VIP     SO XL     VE OUTLOOK     VE PREMIER     VR COMFORT     VR PANAMIC     XL FREEDOM     YO IMAGE     ZEISS GRADAL TOP     ZEISS GRADAL RD     OTHER {SPECIAL INSTRUCTIONS}  

     FRAME TYPE     SELECT ONE     METAL     ZYL     ZYL NO HEAT     NYLON GROOVE RIMLESS     METAL GROOVE RIMLESS     DRILL RIMLESS     FACET GROOVED     FACET DRILLED     OTHER {SPECIAL INSTRUCTIONS}  FRAME    SELECT ONE     TO FOLLOW     ENCLOSED     SUPPLY     DRAWING TO FOLLOW     LENS ONLY {SPECIFY CM}  

     FRAME/MANUF.  COLOR  

     EYE    B    ED   BRIDGE   TEMPLE   CM 

                   MUST HAVE “B” AND “ED” FOR UNCUT!

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