DATE: ACCOUNT NAME: NUMBER:
PATIENT NAME:
ADDRESS:
RIGHT SPH: CYL: AXIS: ADD:
LEFT SPH: CYL: AXIS: ADD:
RIGHT PRISM: BASE DIRECTION:
LEFT PRISM: BASE DIRECTION:
PER EYE DEC. IN: DEC. OUT:
RIGHT SEG HEIGHT: LEFT SEG HEIGHT:
PER EYE SEG INSET: TOTAL INSET: RIGHT PD. DIST: NEAR:
LEFT PD. DIST: NEAR:
MATERIAL :(CHOOSE ONLY ONE TYPE OF MATERIAL) PLASTIC POLYCARBONATE 1.56 INDEX 1.60 INDEX 1.67 INDEX TRIVEX GLASS IF HIGH INDEX SPECIFY INDEX
WILL THIS BE : (CHOOSE ONLY ONE) EDGED UNCUT LENS ONLY
IF LENS ONLY C-SIZE OF LENS
FRAME TO FOLLOW DONALDSON OPTICAL SUPPLIES FRAME LENS ONLY
FRAME NAME: COLOR: EYE SIZE: BRIDGE SIZE: B: E.D.: TEMPLE: ZYL METAL RIMLESS GROOVE DRILLED RIMLESS HALF EYE LENS OPTIONS: RLX UV SOLID TINT COLOR PERCENT GRAD.TINT COLOR PERCENT DOUBLE GRAD. TINT COLORS PERCENT ROLLED EDGES POLISHED EDGES ROLLED AND POLISHED EDGES
(AR --CHOOSE ONLY ONE TYPE OF ANTI REFLECTION COATING)
ZEISS SUPER ET ZEISS GOLD ZEISS BLUE UTMC LABS CHOICE SPECIAL INSTRUCTION:
