RX Order Form
Lab Info
ID
(Required)
Name
Contact
EMail
(Required)
Order Info
Patient Name
Lens
Uncut
or Tray Number
Type
Material
Edge
Frame Included
Frame to Follow
RX
SPH
CYL
Axis
ADD
Power
Seg
Height
Distance P.D.
Near
P.D.
Right
Left
- - - - - - - PRISM #1 - - - - - - -
- - - - - - - PRISM #2 - - - - - - -
Prism
In Out Angle
Prism
Up Dn Angle
Right
Left
A
B
ED
DBL
Frame Type
( Select
)
Frame
Zyl
Metal
Drill
Nylon
Other
Hard
Coat
(Y / N)
AR
Tint
Other
RefFree
(Y / N)
Other
Color
Type
Add Ons
/
/
Lens Shape
#1 Standard
#4 Blended MYO
#2 Bi-Concave Std
#5 Blended MYO CC Front
#3 Standard MYO
#6 Blended MYO
Q
uest
Form
.
Shape not shown or not available
Prism
Shape
Thin Edge
Full
N/A
Special Instructions
