Order Form

Account Info:

*Must have Account Number to process*

Account Number:

Company Name:

E-mail Address:

Ship to Address:

Patient Name:

Ship to Patient:

Patient Address:

OD

Lens Design:

Dyna Intra-Limbal Dyna Cone Plus Dyna Cone Special Reverse Geometry Menifocal Z Single Spherical RGP Post Graft Post Lasik CV-4 Presbylite II Presbylite I Front Toric Base Toric Bitoric Menicon Thin Menicon Alpha1 Dyna Soft Semi-Scleral

Base Curve:

Material:

Power:

Color:

Diameter:

OZ:

Add Power:

Edge Lift:

Standard Flat-1 Flat-2 Flat-3 Flat-4 Steep-1 Steep-2 Steep-3 Steep-4

Warranted:

Non-Warranted:

Dot OD:

Quad Sym design:

Lenticular:

Special Remarks:

OS

Lens Design:

Dyna Intra-Limbal Dyna Cone Dyna Cone Plus Special Reverse Geometry Menifocal Z Single Spherical RGP Post Graft Post Lasik CV-4 Presbylite II Presbylite I Front Toric Base Toric Bitoric Menicon Thin Menicon Alpha1 Dyna Soft Semi-Scleral

Base Curve:

Material:

Power:

Color:

Diameter:

OZ:

Add Power:

Edge Lift:

Standard Flat-1 Flat-2 Flat-3 Flat-4 Steep-1 Steep-2 Steep-3 Steep-4

Warranted:

Non-Warranted:

Quad Sym design:

Lenticular:

Special Remarks:

Lab Design:

Give Spectacle Rx and K Readings

OD:

OS:

Special Remarks:

Solutions

Type

    Quantity

Menicare GP - Menicon

Not Selected Menicare GP Starter Kit Menicare GP CDS (4 oz.) Menicare GP WRW (1 oz.) Progent Starter Kit Progent 7-Pack Cleaner

Optimum - Lobob

Not Selected Optimum Starter Kits Optimum Care System Optimum Hand Soap

Sereine - Extra Strength Daily Cleaner

Not Selected Extra Strength Cleaner (1 oz)

Similasan Natural Eye Drops

Not Selected #1 Dry Eyes (0.33 oz) #2 Allergy Eyes (0.33 oz)

Stronghold Rubber Suction Holders

Not Selected Suction Cups Inserts Both (Suction & Inserts)