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New Rx Order
Account Name:
Date:
21-Dec-2024 09:27 AM
Account Number:
Address:
PRESCRIPTION
Patient/Reference
*
Multi-Pair
Readers Prescription
(Check this box if this order is patient's Readers Prescription)
DISTANCE
R
L
Sphere
*
Cylinder
*
Axis
*
Prism 1
*
Base 1
*
Prism 2
*
Base 2
*
Up
Down
In
Out
Up
Down
In
Out
Up
Down
In
Out
Up
Down
In
Out
READING
R
L
Add
Seg/OC Height(mm)
*
Distance PD(mm)
*
Near PD(mm)
*
Base Curve
JOB / FRAME INFORMATION
Job Type
Uncut Lenses
Edged & Mounted (Frame to Come)
Edged Only (Do Not Mount)
Lab Supply Frame (Edged Mounted)
Frame Brand
Frame Model
*
Frame Colour
Frame Type
*
Full Metal
Full Plastic
Nylon Groove
Rimless (Drill/Notch)
Metal Groove (In-Line)
Other
*
Frame Size
A(mm)
*
B(mm)
*
ED(mm)
*
DBL(mm)
*
Modify Shape
A
Increase
Decrease
by:
mm
B
Increase
Decrease
by:
mm
Safety Thickness
Safety Thickness
Safety Stamp (Edge & Mounted Jobs Only)
(For Safety/Industrial glasses)
Tinting
Solid
Solid + UV
Gradient
Gradient + UV
UV Only
Specify Color
Match Sample
LENS INFORMATION
Type
SV (Stock)
SV (Surfaced)
SV (HD & Anti-Fatigue)
Lined Multi-Focal
Progressive (High Definition)
Progressive
Myopia Control
Special Lenses
*
SPECIAL INSTRUCTIONS
Specify Corridor Length
(Leave unchecked to let lab decide best corridor)
Polish Edges
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