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Order Information

Dispenser Info: * Name * Account # Patient Info: Time Wanted * Patient Name

Lens Information

* Select RX Type:  Please SelectEdge Uncut (Edge or Uncut) * Select Lens Material Glass   Plastic Poly High Index Package Options (optional) MYTEE-LITE Options Transition MYTEE-LITE Package Rep Sport Package Kids Package EPP Program Be U Be Young SupremeH-1 1.60PCASL ASL Transition

iScience Progressives     - Ionic     - Micro     - Biosperic Multifocals     - Aspheric ST 28     - ST-28 Single Vision     - Aspheric SV     - Single Vision

Please Specify Sign *Sphere Cylinder Axis *DIST. NEAR Prism Thickness R 0.00-0.25-0.50-0.75 -1.00-1.25-1.50-1.75-2.00 -2.25-2.50-2.75-3.00-3.25 -3.50-3.75-4.00-4.25-4.50 -4.75-5.00-5.25-5.50 -5.75-6.00-6.25-6.50-6.75 -7.00-7.25-7.50-7.75-8.00 -8.25-8.50-8.75-9.00-9.25 -9.50-9.75-10.00-10.25-10.50 -10.75-11.00-11.25-11.50-11.75-12.00 0.250.500.751.00 1.251.501.752.002.25 2.502.753.003.25 3.503.754.004.254.50 4.755.005.255.505.75 6.006.256.506.757.00 7.257.507.758.00 8.258.508.759.009.25 9.509.7510.0010.2510.50 10.7511.0011.2511.5011.75 12.00 0.00-0.25-0.50-0.75 -1.00-1.25-1.50-1.75-2.00 -2.25-2.50-2.75-3.00-3.25 -3.50-3.75-4.00-4.25-4.50 -4.75-5.00-5.25-5.50 -5.75-6.00-6.25-6.50-6.75 -7.00-7.25-7.50-7.75-8.00 -8.25-8.50-8.75-9.00-9.25 -9.50-9.75-10.00-10.25-10.50 -10.75-11.00-11.25-11.50-11.75-12.00 0.250.500.751.00 1.251.501.752.002.25 2.502.753.003.25 3.503.754.004.254.50 4.755.005.255.505.75 6.006.256.506.757.00 7.257.507.758.00 8.258.508.759.009.25 9.509.7510.0010.2510.50 10.7511.0011.2511.5011.75 12.00 000001002003004 005006007008009010011 012013014015016017018 019020021022023024025 026027028029030031032 033034035036037038039 040041042043044045046 047048049050051052053 054055056057058059060 061062063064065066067 068069070071072073074 075076077078079080081 082083084085086087088 089090091092093094095 096097098099100101102 103104105106107108109 110111112113114115116 117118119120121122123 124125126127128129130 131132133134135136137 138139140141142143144 145146147148149150151 152153154155156157158 159160161162163164165 166167168169170171172 173174175176177178179 180 L 0.00-0.25-0.50-0.75 -1.00-1.25-1.50-1.75-2.00 -2.25-2.50-2.75-3.00-3.25 -3.50-3.75-4.00-4.25-4.50 -4.75-5.00-5.25-5.50 -5.75-6.00-6.25-6.50-6.75 -7.00-7.25-7.50-7.75-8.00 -8.25-8.50-8.75-9.00-9.25 -9.50-9.75-10.00-10.25-10.50 -10.75-11.00-11.25-11.50-11.75-12.00 0.250.500.751.00 1.251.501.752.002.25 2.502.753.003.25 3.503.754.004.254.50 4.755.005.255.505.75 6.006.256.506.757.00 7.257.507.758.00 8.258.508.759.009.25 9.509.7510.0010.2510.50 10.7511.0011.2511.5011.75 12.00 0.00-0.25-0.50-0.75 -1.00-1.25-1.50-1.75-2.00 -2.25-2.50-2.75-3.00-3.25 -3.50-3.75-4.00-4.25-4.50 -4.75-5.00-5.25-5.50 -5.75-6.00-6.25-6.50-6.75 -7.00-7.25-7.50-7.75-8.00 -8.25-8.50-8.75-9.00-9.25 -9.50-9.75-10.00-10.25-10.50 -10.75-11.00-11.25-11.50-11.75-12.00 0.250.500.751.00 1.251.501.752.002.25 2.502.753.003.25 3.503.754.004.254.50 4.755.005.255.505.75 6.006.256.506.757.00 7.257.507.758.00 8.258.508.759.009.25 9.509.7510.0010.2510.50 10.7511.0011.2511.5011.75 12.00 000001002003004 005006007008009010011 012013014015016017018 019020021022023024025 026027028029030031032 033034035036037038039 040041042043044045046 047048049050051052053 054055056057058059060 061062063064065066067 068069070071072073074 075076077078079080081 082083084085086087088 089090091092093094095 096097098099100101102 103104105106107108109 110111112113114115116 117118119120121122123 124125126127128129130 131132133134135136137 138139140141142143144 145146147148149150151 152153154155156157158 159160161162163164165 166167168169170171172 173174175176177178179 180 Style of multifocal Add Height OC Base Blank Sz. R SVST25ST28ST35STT7X25STT7X28STT7X35EXEC TriEXECColored EXECVX ComfortVarilux +VIP1.60 Corning CLR SV1.60 VX Comfort1.60 Percepta1.60 Natural1.52 Photo Thin and Dark SV L

* Lens Color or Tint Roll ScratchCoat   Please SelectFrontBoth UV400 Ultra Crizal Alize Zeiss Advantage Polish  Frame Style Metal ZYL Rimless Half Eye Company (optional)

Frame Information

Frame Name Frame Color * Eye Size mm * DBL mm Temple Size  mm                 Lens Specifications (Uncut or Lenses Only) A mm B mm ED mm C-Size mm Frame Status Lenses Only Supply Frame Frame Enclosed Frame to Come      *Select Branch Location  Please Select Dayton, OH Des Moines, IA Eau Claire, WI Fargo, ND Fort Wayne, IN Jackson, MI La Crosse, WI Madison, WI Oak Creek, WI St. Paul, MN Sioux Falls, SD Terre Haute, IN

Special Instructions

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