Order

Order Information

If the lens options do not meet the needs of the patient, please complete as much of the order form as possible and check the box below to include additional information in the section for special requests.

Please select the lens type from the icons below.*

Single Vision

Bifocal

	Sphere* SPH (Sphere) - Spherical error, or overall power of lens is the basic part of the prescription. Sometimes, the doctor may write 'PL' or 'Plano' - In this case, select +0.00	Cylinder CYL (Cylinder) - Cylinder power indicates correction for astigmatism. This field will default to a negative cylinder power. Plus cylinder can be ordered by adding a + sign before the power. Sometimes, the doctor may write 'Sphere' or 'Sph' in this field. In this case, leave the cylinder and axis fields blank.	Axis Axis - The axis is required for prescriptions with cylinder power. This tells the orientation of the astigmatism.		Addition ADD (Addition) - If your prescription contains ADD or Addition values, this indicates that the patient requires a bifocal lens. Since ADD power is almost always the same in both eyes, it is common for the doctor to only write this once but this should be entered in both eyes.	Seg. Height Segment (Seg) Height - This is the vertical measurement in millimeters from the bottom of the lens to where the top of the addition power should begin. This field is only necessary for multifocal (bifocal or progressive) lenses. Since ADD power is almost always the same in both eyes, it is common for the doctor to only write this once but this should be entered in both eyes. If the prescription contains an Addition (ADD) but does not contain a height measurement it is recommended that you contact the eye doctor or optician to obtain these measurements but if this is not possible, leave blank.
Right Eye (RE or OD)
Left Eye (LE or OS)

Show Additonal Rx fields.

Show fields for Prism and Optical Center.

Distance PD

Distance PD (Pupillary Distance) - The distance in millimeters (mm) between the patient's pupils when they are looking at objects in the distance. This will either be represented with 2 numbers (separate measurements for the left and right eyes) or 1 number (a single measurement between pupils).

RE/OD

LE/OS

Only 1 PD Measurement

Near PD

Near PD (Pupillary Distance) - The distance in millimeters (mm) between the patient's pupils when they are looking at objects close to their face. This will either be represented with 2 numbers (separate measurements for the left and right eyes) or 1 number (a single measurement between pupils). If the prescription contains an Addition (ADD) but does not contain Near PD measurements it is recommended that you contact the eye doctor or optician to obtain these measurements but if this is not possible, leave blank

RE/OD

LE/OS

Only 1 PD Measurement

Lens Design*

Lens Material*

All standard lenses provided are polycarbonate

Lens Name

PLACEHOLDER - TO BE EDIT

Special Requests/Instructions

The lens options above do not meet the medical needs of this patient.

If the above options do not meet the medical needs of the patient, a special request can be made by clicking this check box and completing the special request fields. All special requests are subject to approval.

General Information

Patient Demographic

Order Information

Frame Information

Additional Information