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(If blank, will mail to address on file)  

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Contact Person: 

Patient Info

 
Patient Name: 
Tray

Frame

A B ED DBL
Frame Eye Size: 
Frame Name: 


RX SPH CYL AXIS PRISM BASE OC HGT  
OD   
OS   


ADD SEG HT DIST/
DPD
NEAR
PD
  TOT DEC  
OD     
OS     
Lenses
                     

Treatments Y / N
RLX/SS.....
Foundation.
UV.............

Photochromic
or Polarized
Grey......... Brown
Transition..
SunSensor
InstaShade
Polarized...
Photochromic
None

Material
(Select One)
RLX/SS






. . . Type . . .
(Select One)











Physio
Concise
Precise



Image
Adaptar

Ultra
VIP

. . .Free Form. . .

iForm Adv
Comfort DRx
Comfort Enh
Physio DRx
Physio Enh
Succeed
Succeed Ws
Supercede
Supercede Ws
Autograph II
Spectrum
Element
Definity
Definity 3
Definity 3+


 
 
AR Coatings


Zeiss Carat Adv.
Granite Hard/Slick
Granite Basic ARP
Crizal Easy
Crizal Alize UV
Crizal Avance UV




No Mirror Coating

Tint




   
     
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