MH OPTICAL FSV/STOCK ORDER FORM Account Number:(Required)Account Name(Required) Email(Required) Lens Type---None-------------------------------------------------Same As Above--------------------------------SV 1.50 UC 75mm--------------------------------SV 1.50 UC 60mm--------------------------------SV 1.50 UC 65mm--------------------------------SV 1.50 UC 70mm--------------------------------SV 1.50 HC Tintable 65/70mm----------------SV 1.50 Basic AR 65/70-------------------------SV 1.50 Premium AR 65/70--------------------SV 1.50 Photo Grey------------------------------SV 1.50 Photo Brown----------------------------SV 1.50 Photo Grey AR--------------------------SV 1.50 Photo Brown AR-----------------------SV 1.50 Trans 8 Grey-----------------------------SV 1.50 Trans 8 Brown--------------------------SV 1.50 Trans 8 Grey Premium AR 65/70---SV 1.50 Trans 8 Brown Premium AR 65/70-SV 1.50 XtActive Grey 65/70-------------------SV 1.50 Crizal Easy 65/70-----------------------SV 1.50 Crizal Alize 65/70-----------------------SV 1.50 Crizal Avance 65/70--------------------SV 1.50 Crizal Prevencia 65/70-----------------SV 1.50 Crizal Sapphire 65/70------------------SV 1.50 Trans 8 Grey Alize 65/70--------------SV 1.50 Trans 8 Grey Crizal Avance 65/70---SV 1.50 Trans 8 Brown Crizal Alize 65/70----SV 1.50 Trans 8 Brown Crizal Avance 65/70SV Poly 65/75---------------------------------------SV Poly Tintable 65/75---------------------------SV Poly Aspheric 65mm--------------------------SV Poly Basic AR 65/72---------------------------SV Poly 2.0 Safety 65/70------------------------SV Poly 2.0 Safety AR 65/70--------------------SV Poly Blue Shield 65/70-----------------------SV Poly Blue Shield Premium AR 65/70------SV Poly Kodak Total Blue 65/70--------------------SV Poly Photo Grey 65/70-----------------------SV Poly Photo Brown 65/70---------------------SV Poly Photo Grey AR 65/70-------------------SV Poly Photo Brown AR 65/70----------------SV Poly Shore Blue Select AR----------------SV Poly Trans 8 Grey 65/70---------------------SV Poly Trans 8 Brown 65/70-------------------SV Poly Trans 8 Grey Premium AR 65/70----SV Poly Trans 8 Brown Premium AR 65/70--SV Poly XtActive Grey 65/70--------------------SV Poly Crizal Easy 65/70------------------------SV Poly Crizal Alize 65/70------------------------SV Poly Crizal Avance 65/70--------------------SV Poly Crizal Prevencia 65/70-----------------SV Poly Crizal Sapphire 65/70------------------SV Poly Trans 8 Grey Crizal Avance 65/70---SV 1.56 SunSations Grey 65/70----------------SV 1.56 SunSations Brown 65/70--------------SV 1.56 SunSations Grey AR 65/70------------SV 1.56 SunSations Brown AR 65/70---------SV 1.67 HC 65/70----------------------------------SV 1.67 HC Tintable 65/70----------------------SV 1.67 Basic AR 65/70--------------------------SV 1.67 Premium AR 65/70---------------------SV 1.67 Kodak Total Blue 65/70------------------SV 1.67 Trans 8 Grey 65/70---------------------SV 1.67 Trans 8 Grey Premium AR 65/70----SV 1.67 Trans 8 Brown 65/70-------------------SV 1.67 Trans 8 Brown Premium AR 65/70--SV 1.67 Crizal Easy 65/70-------------------------SV 1.67 Crizal Alize 65/70------------------------SV 1.67 Crizal Avance 65/70---------------------SV 1.67 Crizal Sapphire 65/70-------------------SV 1.67 Trans 8 Grey Crizal Avance 65/70---SV 1.74 Basic AR 65/70---------------------------SV 1.74 Super H AR 65/70------------------------SV 1.74 Trans 8 Grey Super H AR 65/70------SV 1.74 Crizal Avance 65/70---------------------SV 1.60 HC 65/70-----------------------------------SV 1.60 HC Tintable 65/70-----------------------SV 1.60 Basic AR 65/70---------------------------SV 1.60 Premium AR 65/70----------------------SV 1.60 Crizal Avance 65/70---------------------SV Trivex HC 65/70---------------------------------SV Trivex Premium AR-----------------------------SV Trivex Crizal Alize 65/70----------------------FT-28 1.50 UC 70mm------------------------------Progressive 1.50 UC 70mm----------------------Mini Progressive 1.50 UC 70mm---------------SPHPLANO+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00CYLN/A-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00ADDN/A1.001.251.501.752.002.252.502.753.00QNTY (pieces)1234567891011121314151617181920212223242526272829R/L EyeN/ARightLeftPairPatient's Name Lens Type---None-------------------------------------------------Same As Above--------------------------------SV 1.50 UC 75mm--------------------------------SV 1.50 UC 60mm--------------------------------SV 1.50 UC 65mm--------------------------------SV 1.50 UC 70mm--------------------------------SV 1.50 HC Tintable 65/70mm----------------SV 1.50 Basic AR 65/70-------------------------SV 1.50 Premium AR 65/70--------------------SV 1.50 Photo Grey------------------------------SV 1.50 Photo Brown----------------------------SV 1.50 Photo Grey AR--------------------------SV 1.50 Photo Brown AR-----------------------SV 1.50 Trans 8 Grey-----------------------------SV 1.50 Trans 8 Brown--------------------------SV 1.50 Trans 8 Grey Premium AR 65/70---SV 1.50 Trans 8 Brown Premium AR 65/70-SV 1.50 XtActive Grey 65/70-------------------SV 1.50 Crizal Easy 65/70-----------------------SV 1.50 Crizal Alize 65/70-----------------------SV 1.50 Crizal Avance 65/70--------------------SV 1.50 Crizal Prevencia 65/70-----------------SV 1.50 Crizal Sapphire 65/70------------------SV 1.50 Trans 8 Grey Alize 65/70--------------SV 1.50 Trans 8 Grey Crizal Avance 65/70---SV 1.50 Trans 8 Brown Crizal Alize 65/70----SV 1.50 Trans 8 Brown Crizal Avance 65/70SV Poly 65/75---------------------------------------SV Poly Tintable 65/75---------------------------SV Poly Aspheric 65mm--------------------------SV Poly Basic AR 65/72---------------------------SV Poly 2.0 Safety 65/70------------------------SV Poly 2.0 Safety AR 65/70--------------------SV Poly Blue Shield 65/70-----------------------SV Poly Blue Shield Premium AR 65/70------SV Poly Kodak Total Blue 65/70--------------------SV Poly Photo Grey 65/70-----------------------SV Poly Photo Brown 65/70---------------------SV Poly Photo Grey AR 65/70-------------------SV Poly Photo Brown AR 65/70----------------SV Poly Shore Blue Select AR----------------SV Poly Trans 8 Grey 65/70---------------------SV Poly Trans 8 Brown 65/70-------------------SV Poly Trans 8 Grey Premium AR 65/70----SV Poly Trans 8 Brown Premium AR 65/70--SV Poly XtActive Grey 65/70--------------------SV Poly Crizal Easy 65/70------------------------SV Poly Crizal Alize 65/70------------------------SV Poly Crizal Avance 65/70--------------------SV Poly Crizal Prevencia 65/70-----------------SV Poly Crizal Sapphire 65/70------------------SV Poly Trans 8 Grey Crizal Avance 65/70---SV 1.56 SunSations Grey 65/70----------------SV 1.56 SunSations Brown 65/70--------------SV 1.56 SunSations Grey AR 65/70------------SV 1.56 SunSations Brown AR 65/70---------SV 1.67 HC 65/70----------------------------------SV 1.67 HC Tintable 65/70----------------------SV 1.67 Basic AR 65/70--------------------------SV 1.67 Premium AR 65/70---------------------SV 1.67 Kodak Total Blue 65/70------------------SV 1.67 Trans 8 Grey 65/70---------------------SV 1.67 Trans 8 Grey Premium AR 65/70----SV 1.67 Trans 8 Brown 65/70-------------------SV 1.67 Trans 8 Brown Premium AR 65/70--SV 1.67 Crizal Easy 65/70-------------------------SV 1.67 Crizal Alize 65/70------------------------SV 1.67 Crizal Avance 65/70---------------------SV 1.67 Crizal Sapphire 65/70-------------------SV 1.67 Trans 8 Grey Crizal Avance 65/70---SV 1.74 Basic AR 65/70---------------------------SV 1.74 Super H AR 65/70------------------------SV 1.74 Trans 8 Grey Super H AR 65/70------SV 1.74 Crizal Avance 65/70---------------------SV 1.60 HC 65/70-----------------------------------SV 1.60 HC Tintable 65/70-----------------------SV 1.60 Basic AR 65/70---------------------------SV 1.60 Premium AR 65/70----------------------SV 1.60 Crizal Avance 65/70---------------------SV Trivex HC 65/70---------------------------------SV Trivex Premium AR-----------------------------SV Trivex Crizal Alize 65/70----------------------FT-28 1.50 UC 70mm------------------------------Progressive 1.50 UC 70mm----------------------Mini Progressive 1.50 UC 70mm---------------SPHPLANO+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00CYLN/A-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00ADDN/A1.001.251.501.752.002.252.502.753.00R/L EyeN/ARightLeftPairQNTY (pieces)1234567891011121314151617181920212223242526272829Patient's Name Lens Type---None-------------------------------------------------Same As Above--------------------------------SV 1.50 UC 75mm--------------------------------SV 1.50 UC 60mm--------------------------------SV 1.50 UC 65mm--------------------------------SV 1.50 UC 70mm--------------------------------SV 1.50 HC Tintable 65/70mm----------------SV 1.50 Basic AR 65/70-------------------------SV 1.50 Premium AR 65/70--------------------SV 1.50 Photo Grey------------------------------SV 1.50 Photo Brown----------------------------SV 1.50 Photo Grey AR--------------------------SV 1.50 Photo Brown AR-----------------------SV 1.50 Trans 8 Grey-----------------------------SV 1.50 Trans 8 Brown--------------------------SV 1.50 Trans 8 Grey Premium AR 65/70---SV 1.50 Trans 8 Brown Premium AR 65/70-SV 1.50 XtActive Grey 65/70-------------------SV 1.50 Crizal Easy 65/70-----------------------SV 1.50 Crizal Alize 65/70-----------------------SV 1.50 Crizal Avance 65/70--------------------SV 1.50 Crizal Prevencia 65/70-----------------SV 1.50 Crizal Sapphire 65/70------------------SV 1.50 Trans 8 Grey Alize 65/70--------------SV 1.50 Trans 8 Grey Crizal Avance 65/70---SV 1.50 Trans 8 Brown Crizal Alize 65/70----SV 1.50 Trans 8 Brown Crizal Avance 65/70SV Poly 65/75---------------------------------------SV Poly Tintable 65/75---------------------------SV Poly Aspheric 65mm--------------------------SV Poly Basic AR 65/72---------------------------SV Poly 2.0 Safety 65/70------------------------SV Poly 2.0 Safety AR 65/70--------------------SV Poly Blue Shield 65/70-----------------------SV Poly Blue Shield Premium AR 65/70------SV Poly Kodak Total Blue 65/70--------------------SV Poly Photo Grey 65/70-----------------------SV Poly Photo Brown 65/70---------------------SV Poly Photo Grey AR 65/70-------------------SV Poly Photo Brown AR 65/70----------------SV Poly Shore Blue Select AR----------------SV Poly Trans 8 Grey 65/70---------------------SV Poly Trans 8 Brown 65/70-------------------SV Poly Trans 8 Grey Premium AR 65/70----SV Poly Trans 8 Brown Premium AR 65/70--SV Poly XtActive Grey 65/70--------------------SV Poly Crizal Easy 65/70------------------------SV Poly Crizal Alize 65/70------------------------SV Poly Crizal Avance 65/70--------------------SV Poly Crizal Prevencia 65/70-----------------SV Poly Crizal Sapphire 65/70------------------SV Poly Trans 8 Grey Crizal Avance 65/70---SV 1.56 SunSations Grey 65/70----------------SV 1.56 SunSations Brown 65/70--------------SV 1.56 SunSations Grey AR 65/70------------SV 1.56 SunSations Brown AR 65/70---------SV 1.67 HC 65/70----------------------------------SV 1.67 HC Tintable 65/70----------------------SV 1.67 Basic AR 65/70--------------------------SV 1.67 Premium AR 65/70---------------------SV 1.67 Kodak Total Blue 65/70------------------SV 1.67 Trans 8 Grey 65/70---------------------SV 1.67 Trans 8 Grey Premium AR 65/70----SV 1.67 Trans 8 Brown 65/70-------------------SV 1.67 Trans 8 Brown Premium AR 65/70--SV 1.67 Crizal Easy 65/70-------------------------SV 1.67 Crizal Alize 65/70------------------------SV 1.67 Crizal Avance 65/70---------------------SV 1.67 Crizal Sapphire 65/70-------------------SV 1.67 Trans 8 Grey Crizal Avance 65/70---SV 1.74 Basic AR 65/70---------------------------SV 1.74 Super H AR 65/70------------------------SV 1.74 Trans 8 Grey Super H AR 65/70------SV 1.74 Crizal Avance 65/70---------------------SV 1.60 HC 65/70-----------------------------------SV 1.60 HC Tintable 65/70-----------------------SV 1.60 Basic AR 65/70---------------------------SV 1.60 Premium AR 65/70----------------------SV 1.60 Crizal Avance 65/70---------------------SV Trivex HC 65/70---------------------------------SV Trivex Premium AR-----------------------------SV Trivex Crizal Alize 65/70----------------------FT-28 1.50 UC 70mm------------------------------Progressive 1.50 UC 70mm----------------------Mini Progressive 1.50 UC 70mm---------------SPHPLANO+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00CYLN/A-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00ADDN/A1.001.251.501.752.002.252.502.753.00R/L EyeN/ARightLeftPairQNTY (pieces)1234567891011121314151617181920212223242526272829Patient's Name Lens Type---None-------------------------------------------------Same As Above--------------------------------SV 1.50 UC 75mm--------------------------------SV 1.50 UC 60mm--------------------------------SV 1.50 UC 65mm--------------------------------SV 1.50 UC 70mm--------------------------------SV 1.50 HC Tintable 65/70mm----------------SV 1.50 Basic AR 65/70-------------------------SV 1.50 Premium AR 65/70--------------------SV 1.50 Photo Grey------------------------------SV 1.50 Photo Brown----------------------------SV 1.50 Photo Grey AR--------------------------SV 1.50 Photo Brown AR-----------------------SV 1.50 Trans 8 Grey-----------------------------SV 1.50 Trans 8 Brown--------------------------SV 1.50 Trans 8 Grey Premium AR 65/70---SV 1.50 Trans 8 Brown Premium AR 65/70-SV 1.50 XtActive Grey 65/70-------------------SV 1.50 Crizal Easy 65/70-----------------------SV 1.50 Crizal Alize 65/70-----------------------SV 1.50 Crizal Avance 65/70--------------------SV 1.50 Crizal Prevencia 65/70-----------------SV 1.50 Crizal Sapphire 65/70------------------SV 1.50 Trans 8 Grey Alize 65/70--------------SV 1.50 Trans 8 Grey Crizal Avance 65/70---SV 1.50 Trans 8 Brown Crizal Alize 65/70----SV 1.50 Trans 8 Brown Crizal Avance 65/70SV Poly 65/75---------------------------------------SV Poly Tintable 65/75---------------------------SV Poly Aspheric 65mm--------------------------SV Poly Basic AR 65/72---------------------------SV Poly 2.0 Safety 65/70------------------------SV Poly 2.0 Safety AR 65/70--------------------SV Poly Blue Shield 65/70-----------------------SV Poly Blue Shield Premium AR 65/70------SV Poly Kodak Total Blue 65/70--------------------SV Poly Photo Grey 65/70-----------------------SV Poly Photo Brown 65/70---------------------SV Poly Photo Grey AR 65/70-------------------SV Poly Photo Brown AR 65/70----------------SV Poly Shore Blue Select AR----------------SV Poly Trans 8 Grey 65/70---------------------SV Poly Trans 8 Brown 65/70-------------------SV Poly Trans 8 Grey Premium AR 65/70----SV Poly Trans 8 Brown Premium AR 65/70--SV Poly XtActive Grey 65/70--------------------SV Poly Crizal Easy 65/70------------------------SV Poly Crizal Alize 65/70------------------------SV Poly Crizal Avance 65/70--------------------SV Poly Crizal Prevencia 65/70-----------------SV Poly Crizal Sapphire 65/70------------------SV Poly Trans 8 Grey Crizal Avance 65/70---SV 1.56 SunSations Grey 65/70----------------SV 1.56 SunSations Brown 65/70--------------SV 1.56 SunSations Grey AR 65/70------------SV 1.56 SunSations Brown AR 65/70---------SV 1.67 HC 65/70----------------------------------SV 1.67 HC Tintable 65/70----------------------SV 1.67 Basic AR 65/70--------------------------SV 1.67 Premium AR 65/70---------------------SV 1.67 Kodak Total Blue 65/70------------------SV 1.67 Trans 8 Grey 65/70---------------------SV 1.67 Trans 8 Grey Premium AR 65/70----SV 1.67 Trans 8 Brown 65/70-------------------SV 1.67 Trans 8 Brown Premium AR 65/70--SV 1.67 Crizal Easy 65/70-------------------------SV 1.67 Crizal Alize 65/70------------------------SV 1.67 Crizal Avance 65/70---------------------SV 1.67 Crizal Sapphire 65/70-------------------SV 1.67 Trans 8 Grey Crizal Avance 65/70---SV 1.74 Basic AR 65/70---------------------------SV 1.74 Super H AR 65/70------------------------SV 1.74 Trans 8 Grey Super H AR 65/70------SV 1.74 Crizal Avance 65/70---------------------SV 1.60 HC 65/70-----------------------------------SV 1.60 HC Tintable 65/70-----------------------SV 1.60 Basic AR 65/70---------------------------SV 1.60 Premium AR 65/70----------------------SV 1.60 Crizal Avance 65/70---------------------SV Trivex HC 65/70---------------------------------SV Trivex Premium AR-----------------------------SV Trivex Crizal Alize 65/70----------------------FT-28 1.50 UC 70mm------------------------------Progressive 1.50 UC 70mm----------------------Mini Progressive 1.50 UC 70mm---------------SPHPLANO+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00CYLN/A-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00ADDN/A1.001.251.501.752.002.252.502.753.00R/L EyeN/ARightLeftPairQNTY (pieces)1234567891011121314151617181920212223242526272829Patient's Name Lens Type---None-------------------------------------------------Same As Above--------------------------------SV 1.50 UC 75mm--------------------------------SV 1.50 UC 60mm--------------------------------SV 1.50 UC 65mm--------------------------------SV 1.50 UC 70mm--------------------------------SV 1.50 HC Tintable 65/70mm----------------SV 1.50 Basic AR 65/70-------------------------SV 1.50 Premium AR 65/70--------------------SV 1.50 Photo Grey------------------------------SV 1.50 Photo Brown----------------------------SV 1.50 Photo Grey AR--------------------------SV 1.50 Photo Brown AR-----------------------SV 1.50 Trans 8 Grey-----------------------------SV 1.50 Trans 8 Brown--------------------------SV 1.50 Trans 8 Grey Premium AR 65/70---SV 1.50 Trans 8 Brown Premium AR 65/70-SV 1.50 XtActive Grey 65/70-------------------SV 1.50 Crizal Easy 65/70-----------------------SV 1.50 Crizal Alize 65/70-----------------------SV 1.50 Crizal Avance 65/70--------------------SV 1.50 Crizal Prevencia 65/70-----------------SV 1.50 Crizal Sapphire 65/70------------------SV 1.50 Trans 8 Grey Alize 65/70--------------SV 1.50 Trans 8 Grey Crizal Avance 65/70---SV 1.50 Trans 8 Brown Crizal Alize 65/70----SV 1.50 Trans 8 Brown Crizal Avance 65/70SV Poly 65/75---------------------------------------SV Poly Tintable 65/75---------------------------SV Poly Aspheric 65mm--------------------------SV Poly Basic AR 65/72---------------------------SV Poly 2.0 Safety 65/70------------------------SV Poly 2.0 Safety AR 65/70--------------------SV Poly Blue Shield 65/70-----------------------SV Poly Blue Shield Premium AR 65/70------SV Poly Kodak Total Blue 65/70--------------------SV Poly Photo Grey 65/70-----------------------SV Poly Photo Brown 65/70---------------------SV Poly Photo Grey AR 65/70-------------------SV Poly Photo Brown AR 65/70----------------SV Poly Shore Blue Select AR----------------SV Poly Trans 8 Grey 65/70---------------------SV Poly Trans 8 Brown 65/70-------------------SV Poly Trans 8 Grey Premium AR 65/70----SV Poly Trans 8 Brown Premium AR 65/70--SV Poly XtActive Grey 65/70--------------------SV Poly Crizal Easy 65/70------------------------SV Poly Crizal Alize 65/70------------------------SV Poly Crizal Avance 65/70--------------------SV Poly Crizal Prevencia 65/70-----------------SV Poly Crizal Sapphire 65/70------------------SV Poly Trans 8 Grey Crizal Avance 65/70---SV 1.56 SunSations Grey 65/70----------------SV 1.56 SunSations Brown 65/70--------------SV 1.56 SunSations Grey AR 65/70------------SV 1.56 SunSations Brown AR 65/70---------SV 1.67 HC 65/70----------------------------------SV 1.67 HC Tintable 65/70----------------------SV 1.67 Basic AR 65/70--------------------------SV 1.67 Premium AR 65/70---------------------SV 1.67 Kodak Total Blue 65/70------------------SV 1.67 Trans 8 Grey 65/70---------------------SV 1.67 Trans 8 Grey Premium AR 65/70----SV 1.67 Trans 8 Brown 65/70-------------------SV 1.67 Trans 8 Brown Premium AR 65/70--SV 1.67 Crizal Easy 65/70-------------------------SV 1.67 Crizal Alize 65/70------------------------SV 1.67 Crizal Avance 65/70---------------------SV 1.67 Crizal Sapphire 65/70-------------------SV 1.67 Trans 8 Grey Crizal Avance 65/70---SV 1.74 Basic AR 65/70---------------------------SV 1.74 Super H AR 65/70------------------------SV 1.74 Trans 8 Grey Super H AR 65/70------SV 1.74 Crizal Avance 65/70---------------------SV 1.60 HC 65/70-----------------------------------SV 1.60 HC Tintable 65/70-----------------------SV 1.60 Basic AR 65/70---------------------------SV 1.60 Premium AR 65/70----------------------SV 1.60 Crizal Avance 65/70---------------------SV Trivex HC 65/70---------------------------------SV Trivex Premium AR-----------------------------SV Trivex Crizal Alize 65/70----------------------FT-28 1.50 UC 70mm------------------------------Progressive 1.50 UC 70mm----------------------Mini Progressive 1.50 UC 70mm---------------SPHPLANO+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00CYLN/A-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00ADDN/A1.001.251.501.752.002.252.502.753.00R/L EyeN/ARightLeftPairQNTY (pieces)1234567891011121314151617181920212223242526272829Patient's Name Lens Type---None-------------------------------------------------Same As Above--------------------------------SV 1.50 UC 75mm--------------------------------SV 1.50 UC 60mm--------------------------------SV 1.50 UC 65mm--------------------------------SV 1.50 UC 70mm--------------------------------SV 1.50 HC Tintable 65/70mm----------------SV 1.50 Basic AR 65/70-------------------------SV 1.50 Premium AR 65/70--------------------SV 1.50 Photo Grey------------------------------SV 1.50 Photo Brown----------------------------SV 1.50 Photo Grey AR--------------------------SV 1.50 Photo Brown AR-----------------------SV 1.50 Trans 8 Grey-----------------------------SV 1.50 Trans 8 Brown--------------------------SV 1.50 Trans 8 Grey Premium AR 65/70---SV 1.50 Trans 8 Brown Premium AR 65/70-SV 1.50 XtActive Grey 65/70-------------------SV 1.50 Crizal Easy 65/70-----------------------SV 1.50 Crizal Alize 65/70-----------------------SV 1.50 Crizal Avance 65/70--------------------SV 1.50 Crizal Prevencia 65/70-----------------SV 1.50 Crizal Sapphire 65/70------------------SV 1.50 Trans 8 Grey Alize 65/70--------------SV 1.50 Trans 8 Grey Crizal Avance 65/70---SV 1.50 Trans 8 Brown Crizal Alize 65/70----SV 1.50 Trans 8 Brown Crizal Avance 65/70SV Poly 65/75---------------------------------------SV Poly Tintable 65/75---------------------------SV Poly Aspheric 65mm--------------------------SV Poly Basic AR 65/72---------------------------SV Poly 2.0 Safety 65/70------------------------SV Poly 2.0 Safety AR 65/70--------------------SV Poly Blue Shield 65/70-----------------------SV Poly Blue Shield Premium AR 65/70------SV Poly Kodak Total Blue 65/70--------------------SV Poly Photo Grey 65/70-----------------------SV Poly Photo Brown 65/70---------------------SV Poly Photo Grey AR 65/70-------------------SV Poly Photo Brown AR 65/70----------------SV Poly Shore Blue Select AR----------------SV Poly Trans 8 Grey 65/70---------------------SV Poly Trans 8 Brown 65/70-------------------SV Poly Trans 8 Grey Premium AR 65/70----SV Poly Trans 8 Brown Premium AR 65/70--SV Poly XtActive Grey 65/70--------------------SV Poly Crizal Easy 65/70------------------------SV Poly Crizal Alize 65/70------------------------SV Poly Crizal Avance 65/70--------------------SV Poly Crizal Prevencia 65/70-----------------SV Poly Crizal Sapphire 65/70------------------SV Poly Trans 8 Grey Crizal Avance 65/70---SV 1.56 SunSations Grey 65/70----------------SV 1.56 SunSations Brown 65/70--------------SV 1.56 SunSations Grey AR 65/70------------SV 1.56 SunSations Brown AR 65/70---------SV 1.67 HC 65/70----------------------------------SV 1.67 HC Tintable 65/70----------------------SV 1.67 Basic AR 65/70--------------------------SV 1.67 Premium AR 65/70---------------------SV 1.67 Kodak Total Blue 65/70------------------SV 1.67 Trans 8 Grey 65/70---------------------SV 1.67 Trans 8 Grey Premium AR 65/70----SV 1.67 Trans 8 Brown 65/70-------------------SV 1.67 Trans 8 Brown Premium AR 65/70--SV 1.67 Crizal Easy 65/70-------------------------SV 1.67 Crizal Alize 65/70------------------------SV 1.67 Crizal Avance 65/70---------------------SV 1.67 Crizal Sapphire 65/70-------------------SV 1.67 Trans 8 Grey Crizal Avance 65/70---SV 1.74 Basic AR 65/70---------------------------SV 1.74 Super H AR 65/70------------------------SV 1.74 Trans 8 Grey Super H AR 65/70------SV 1.74 Crizal Avance 65/70---------------------SV 1.60 HC 65/70-----------------------------------SV 1.60 HC Tintable 65/70-----------------------SV 1.60 Basic AR 65/70---------------------------SV 1.60 Premium AR 65/70----------------------SV 1.60 Crizal Avance 65/70---------------------SV Trivex HC 65/70---------------------------------SV Trivex Premium AR-----------------------------SV Trivex Crizal Alize 65/70----------------------FT-28 1.50 UC 70mm------------------------------Progressive 1.50 UC 70mm----------------------Mini Progressive 1.50 UC 70mm---------------SPHPLANO+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00CYLN/A-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00ADDN/A1.001.251.501.752.002.252.502.753.00R/L EyeN/ARightLeftPairQNTY (pieces)1234567891011121314151617181920212223242526272829Patient's Name Instructions:
