Acct Name/Location: 

Account # (Required)

Mailing Address: 
(If blank, will mail to address on file)  

Patient Info

To Follow Supply Uncut

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

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

Material
(Select One)
CR39
CR39 RLX/SS
1.60
1.66/67
1.70
1.74
Polycarbonate
Trivex
Glass

. . . Type . . .
(Select One)
SV
FT 28
FT 35
Round 22
Executive
Blended
Tri-Focal
7x28
8x35

. . .Prog - Trad . . .
Exceed
Exceed Mini
Comfort 2
Physio
Concise
Precise
GT2
GT2 Short
Natural
Image
Adaptar
Compact
Compact Ultra
VIP

. . .Free Form. . .
iForm
iForm Adv
Exceed Delux
Comfort DRx
Comfort Enh
Physio DRx
Physio Enh
Succeed
Succeed Ws
Supercede
Supercede Ws
Autograph II
Spectrum
Element
Definity
Definity 3
Definity 3+

 Other-Specify

. . . . . . . . . . . . . . . .
Cool Blue Mirror
Cool Silver Mirror
Cool Gold Mirror
No Mirror Coating

Tint
None
Gradient
Solid
Percent
Color.........

Schedule
Network
PDS

Fedex
UPS
Pick Up