New Hampshire Optical

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Account Information

Note: Red fields are required

Acct Name/Location

Account #

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

Phone Number

E-Mail Address

Contact Person

Patient Info

Patient Name

Tray

FRAME

Uncut
Edge Only
Supply
2Follow
Call W/Ready

Metal
Zyl
Drill
Groove

Frame Packages ( None)
Value Line

1 2 3 4
Back to School

Jelly Bean

Mfg

Name

Eye Size

DBL

Temple

Circumference

Color

Edge Type Roll& Polish Polish Edges Regular

Wrap Frame Yes No

SPH

CYL

AXIS

PRISM

BASE

OC HGT

ADD

SEG HT

DIST/
DPD

NEAR
PD

TOT DEC

Lenses

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

Photochromic
or Polarized
Grey......... Brown
None..............
Transition..
SunSensor
InstaShade
Polarized...
PGX.........
Thin&Dark
DriveWear
Life RX
Other-Specify

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
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

AR Coatings
Zeiss Gold ET
Zeiss Super ET
Zeiss Carat Adv.
Granite Hard/Slick
Granite Basic ARP
Crizal Easy
Crizal Alize UV
Crizal Avance UV
No AR

* Lab choice of Carat, Crizal, Granite or CleAR to expedite service.

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

Special Instructions