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E-Mail Address: *
Phone: *
Account Name: *
City: *
Date:
Patient Name: *
Frame Name/Manufacturer: *
Lens Size: *
Bridge: *
Temple:

A Size:
B Size:
ED Size:
C Size:
Color:
To Come  Lens Only
ENC


EDGING INFORMATION
ZYL METAL
RIMLESS DRILL MT
Roll & Polish Polish
All Metal
        Groove
Roll

TINT INFORMATION   (Pick at least one!)
CLEAR COLOR  
SOLID Double Gradient
Gradient Match Sample
Transitions
  Grey NG
  Brown NG
Polarized
  grey
  Brown
  Color
Other
  Specify  

Lens Info
FIN UNCUT
STOCK LENS SV
BIFOCAL EXECUTIVE
FLAT TOP
          22    25    28    35    
ROUND SEG

TRIFOCAL
7/25 7/28 8/35 Exec Tri

PROGRESSIVE
GT2 Accolade Compact Ultra
GT2-Short Natural AO Compact
Younger Image Other
     Specify:
 

COATING INFO
Blue Ice Carat Carat Advantage
Zeiss ET Zeiss Gold  
2 Year Warranty (LD2) OTHER
     Specify:

Plastic
CR-39 1.66/1.67 1.56/1.57 Aspheric UV Block
Fact. SRC 1.60 Other Trivex  

Poly
Regular Poly Aspheric 1.0 mm  

Glass
Crown Glass PGX PBX 1.60
1.70 Other   

Thickness
1.5 mm 2.2 mm 3.3 mm Ind      mm

Special Instructions

Distance
  SPHERE * CYLINDER AXIS PRISM BASE OC
R *
L *
  ADD SEG HEIGHT DISTANCE PD * NEAR PD DEC SEG INSET
R *
L *

Remake Info
Invoice Date:   Invoice #:  

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