On-Line Ordering

DATE ORDERED ACCOUNT NUMBER INVOICE NUMBER PATIENT NAME





MATERIAL

TINT

COATING

EDGING


CLEAR
COLOR
SOLID
GRADIENT
MATCH ENCLOSED SAMPLE
SPECIAL TINTING INSTRUCTIONS
SCRATCH RESIS. COATING
ULTRAVIOLET COATING
ANTI-REFLECTIVE COATING
MIRROR COATING
AR TYPE

AR DESCRIPTION
COATING MIRRROR
POLISH EDGES
ROLL & POLISH

 

SPHERE

CYLINDER

AXIS

PRISM

OC HT

DPD

NPD

OD

OS

 SPECIAL INSTRUCTIONS

 FRAME INFORMATION



   FRAME ENCLOSED
   FRAME TO COME

SHIP TO

 MANUFACTURER INFORMATION


MANUFACTURER
 MODEL NO.

LAB USE ONLY

COLOR / SIZE INFORMATION

  Color
  		 METAL ZYL RIMLESS

  SIZE
B:
ED:
DBL: