* 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: