.
 
 
Use Mouse to Point & Click or Tab to enter order. Do not press ENTER key, this will submit order.
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

Edge Only
Supply
2Follow
Call W/Ready
Frame Packages ( None)
1 2 3 4
 
Mfg
Name
Eye Size
DBL Temple

 

A B ED
Circumference
Color
 
 
 

Edge Type Roll& Polish Polish Edges Regular

 
Wrap Frame Yes No
RX
SPH
CYL
AXIS
PRISM
BASE
OC HGT
 
OD 
 
OS 
 


ADD
SEG HT
DIST/
DPD
NEAR
PD
TOT DEC
 
OD 
 
OS 
 
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)
RLX/SS





Type . . . . . . . .
(Select One)











Physio
Concise
Precise



Image
Adaptar

Ultra
VIP



 
AR Coatings


Zeiss Carat Adv.
Granite Hard/Slick
Granite Basic ARP
Crizal Easy
Crizal Alize UV
Crizal Avance UV


Tint




 
     
Special Instructions  


 
Copyright© of New Hampshire Optical. 2008 All Rights Reserved.