Midwest Lens - Online Rx Order Form
(
*
red asterisk denotes required field )
*
Account Number:
*
Pair
Right Only
Left Only
Patient Last Name:
Patient First Name:
Medicaid
Right Eye:
Sphere:
+
-
Cylinder:
+
-
Axis:
PD Distance:
PD Near:
Left Eye:
Sphere:
+
-
Cylinder:
+
-
Axis:
PD Distance:
PD Near:
Right Eye:
Add:
Seg Height:
Prism:
In
Out
Up
Down
Left Eye:
Add:
Seg Height:
Prism:
In
Out
Up
Down
*
Lens Style:
Single Vision
Aspheric Single Vision
Aspheric Lenticular Single Vision
-----------------------------------------------------
Perfecta Single Vision (Midwest Lens)
Perfecta Ease Single Vision (Midwest Lens)
-----------------------------------------------------
FT 25
FT 28
FT 35
FT 45
Round 22
Blended Bifocal 28
Curve Top 28
Executive Bifocal
Occupational FT 25
Occupational FT 28
Occupational FT 35
Occupational Round 22
-----------------------------------------------------
7x25
7x28
7x35
8x35
10x35
12x35
14x35
Executive Trifocal
Quadrifocal 7x25
Quadrifocal 7x28
Quadrifocal 7x35
-----------------------------------------------------
Progressive
Progressive Style:
Perfecta (Midwest Lens)
Perfecta Professional (Midwest Lens)
-----------------------------------------------------
Compact (AO)
Easy (AO)
-----------------------------------------------------
Navigator (Armorlite)
Navigator Short (Armorlite)
-----------------------------------------------------
Trinity (Augen)
Trinity Short (Augen)
-----------------------------------------------------
Accolade (Essilor)
Accolade Freedom (Essilor)
Adaptar (Essilor)
Definity (Essilor)
Definity Short (Essilor)
Natural (Essilor)
Ovation (Essilor)
SmallFit (Essilor)
Super No-Line (Essilor)
-----------------------------------------------------
PAL (Kodak)
Concise (Kodak)
Precise (Kodak)
Precise Short (Kodak)
Unique (Kodak)
-----------------------------------------------------
AF2 (Seiko)
Proceed II (Seiko)
Proceed III (Seiko)
Succeed (Seiko)
Supercede (Seiko)
Surmount (Seiko)
-----------------------------------------------------
ShoreView (Shore)
ShoreView Mini (Shore)
-----------------------------------------------------
Access (Sola)
Compact Ultra (Sola)
SOLAOne (Sola)
SOLAMAX (Sola)
VIP (Sola)
-----------------------------------------------------
Comfort (Varilux)
Comfort Short (Varilux)
Comfort Enhanced (Varilux)
Comfort 360 (Varilux)
Comfort Short 360 (Varilux)
Comfort DRx (Varilux)
Comfort Short DRx (Varilux)
Ellipse (Varilux)
Ellipse 360 (Varilux)
Physio (Varilux)
Physio Short (Varilux)
Physio Enhanced (Varilux)
Physio 360 (Varilux)
Physio Short 360 (Varilux)
Physio DRx (Varilux)
Physio Short DRx (Varilux)
S Design (Varilux)
S Fit (Varilux)
S 4D (Varilux)
-----------------------------------------------------
Illumina (Vision-Ease)
Outlook (Vision-Ease)
-----------------------------------------------------
Freedom ID (X-Cel)
-----------------------------------------------------
Adage (Younger)
Image (Younger)
-----------------------------------------------------
Gradal RD (Zeiss)
Gradal Top (Zeiss)
GT2 (Zeiss)
GT2 Short (Zeiss)
*
Lens Material:
CR39 Plastic
Polycarbonate
Trivex
Mid-Index 1.56
1.67
1.70
1.74
Glass
Glass Color/Photochromatic:
Clear
G-15
Gray 1
Gray 2
Gray 3
Green 1
Green 2
Green 3
Polarized Gray 3
Rose 1 (Crux A)
Rose 2 (Crux AX)
-----------------------------------------------------
PhotoGray Extra (PGX)
Photobrown Extra (PBX)
Thin & Dark Gray
Thin & Dark Brown
Photochromatic:
Transitions Gray
Transitions Brown
SunSensors Gray
Sunsensors Brown
Transitions XTRActive Gray
Transitions Vantage
Drivewear Transitions
Polarized:
Polarized Gray 1
Polarized Gray 3
Polarized Brown 1
Polarized Brown 3
Polarized G15
Edge:
Standard
Polish
Roll
Roll and Polish
Grind:
Standard
Thin 1.0
Safety
Slab-Off
Lab Tint:
Blue 1
Blue 2
Blue 3
Blue Blush 1
Blue Blush 2
Brown 1
Brown 2
Brown 3
Crux
Crux A
Crux AX
G-15
Gray 1
Gray 2
Gray 3
Green 1
Green 2
Green 3
Pearl 1
Pearl 2
Pearl 3
Purple 1
Purple 2
Purple 3
Rose 1
Rose 2
Rose 3
Yellow 1
Yellow 2
Yellow 3
Tint Type:
Solid
Gradient
Double Gradient
Coatings:
Scratch Resistant Coating
UV-400 (Ultra Violet Filter)
Tuff Kote
AR Coatings:
Titan AR
Titan Plus AR
Titan Elite AR
Crizal Easy UV
Crizal Alize UV
Crizal Avance UV
Other Coats:
Frame Information:
Frame Name:
Eye Size:
DBL:
B:
ED:
Circumference:
Temple Length:
Frame Color:
( Frames supplied from Midwest Lens require a frame color specification )
Frame Type:
Metal
Plastic
Rimless Groove
Rimless Drill
--------------------------
Industrial Metal
Industrial Plastic
Industrial Rimless Groove
Industrial Rimless Drill
*
Frame Status:
Frame To Come
Lens Only
Lab Supply Frame
Pattern To Come
Uncut
Additional Instructions or Comments:
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