RX ORDER FORM
» Lab Info

Customer ID
Customer Name*
Email Address*


» Order Info

Patient Name or Tray #
Lens Type
Lens Material


Uncut Edged

» RX
 
SPH
CYL
AXIS
ADD
SEG HT
DIST PD
NEAR PD

Right

Left


Prism Right

Prism Left


» Frame

A
B
ED
DBL



Metal
ZYL
Drill
Nylon
Info:

» Add Ons

Hardcoat
NO AR
AR
AR E
AR H
AR HE


Tint:

Special Instructions: