Midwest Lens - Web Order Form
(
*
red asterisk denotes required field )
*
Account Number:
*
Pair
Right Only
Left Only
Patient Name:
(First) Name:
(Last) Name:
Right Eye:
Sphere:
+
-
Cylinder:
+
-
Axis:
PD Distance:
PD Near:
Left Eye:
Sphere:
+
-
Cylinder:
+
-
Axis:
PD Distance:
PD Near:
Right Eye:
Prism:
In
Out
Up
Down
Left Eye:
Prism:
In
Out
Up
Down
Right Eye:
Add:
Seg Height:
OC:
Base Curve:
Left Eye:
Add:
Seg Height:
OC:
Base Curve:
*
Lens Style:
Progressive
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Single Vision Standard
Single Vision Aspheric
Single Vision 1.53 Trilogy
Single Vision 1.54
Single Vision 1.54 Spectralite
Single Vision 1.56
Single Vision 1.56 Aspheric
Single Vision 1.57
Single Vision 1.60
Single Vision 1.60 Aspheric
Single Vision 1.67
Single Vision 1.74 with Crizal Alizé
Lenticular Aspheric Single Vision
Full Field Aspheric Single Vision
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FT 25
FT 28
FT 28 1.53 Trilogy
FT 28 1.54
FT 28 1.54 Spectralite
FT 28 1.56
FT 28 1.60
FT 28 1.66 Aspheric
FT 35
FT 35 1.56
FT 45
Round 22
Round 24
Executive Bifocal
Ultex A
Sola Smart Seg
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7x25
7x28
7x28 1.54
7x28 1.56
7x35
8x35
8x35 1.56
Executive Trifocal
10x35
14x35
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Double Exec/Exec
Double FT 25/25
Double FT 28/28
Double FT 35/35
QuadFocal FT 25/7x25
QuadFocal FT 28/7x28
QuadFocal FT 35/7x35
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Full Field Aspheric FT 22
Full Field Aspheric Round 22
Lenticular Aspheric FT 22
Lenticular Aspheric Round 22
Progressive Style:
b'Active (AO)
Compact (AO)
Compact 1.60 (AO)
Compact 1.67 (AO)
Easy (AO)
Easy 1.60 (AO)
Easy 1.67 (AO)
Force 1.55 (AO)
Pro 15 (AO)
Pro 1.60 (AO)
TruVision (AO)
TruVision Omni (AO)
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Centurion (Augen)
Centurion Short (Augen)
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Accolade (Essilor)
Accolade 1.60 (Essilor)
Accolade 1.67 (Essilor)
Accolade 1.74 (Essilor)
Adaptar (Essilor)
Definity (Essilor)
Definity Trivex (Essilor)
Definity 1.60 (Essilor)
Definity 1.67 (Essilor)
Definity Short (Essilor)
Definity Short Trivex (Essilor)
Definity Short 1.60 (Essilor)
Definity Short 1.67 (Essilor)
Interview (Essilor)
Natural (Essilor)
Ovation (Essilor)
Ovation 1.67 (Essilor)
PRIO (Essilor)
SmallFit (Essilor)
Super NoLine (Essilor)
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GP Wide (Hoya)
iD (Hoya)
iD LifeStyle (Hoya)
Summit CD (Hoya)
Summit ECP (Hoya)
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Hyperindex 1.66 (OP)
Hyperview 1.66 (OP)
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AF (Pentax)
AF Mini (Pentax)
AF 1.60 (Pentax)
AF Mini 1.60 (Pentax)
AF 1.67 (Pentax)
AF Mini 1.67 (Pentax)
DiamondClear Mini (Pentax)
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Proceed 1.67 (Seiko)
Proceed II Short 1.67 (Seiko)
Proceed III Super Short 1.67 (Seiko)
Succeed (Seiko)
Succeed 1.60 (Seiko)
Succeed 1.67 (Seiko)
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Creation (Shamir)
Creation 1.60 (Shamir)
Creation 1.67 (Shamir)
Attitude 1.60 (Shamir)
Autograph (Shamir)
Autograph 1.60 (Shamir)
Autograph 1.67 (Shamir)
Genesis (Shamir)
Genesis 1.60 (Shamir)
Genesis 1.67 (Shamir)
Genesis Trivex (Shamir)
Office (Shamir)
Piccolo (Shamir)
Piccolo 1.60 (Shamir)
Piccolo 1.67 (Shamir)
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Kodak (Signet)
Kodak 1.56 (Signet)
Kodak 1.60 (Signet)
Kodak Concise (Signet)
Kodak Concise 1.56 (Signet)
Kodak Concise 1.60 (Signet)
Kodak Concise 1.67 (Signet)
Kodak Concise TLX1.6 (Signet)
Kodak Concise Trivex (Signet)
Kodak Precise (Signet)
Kodak Precise 1.56 (Signet)
Kodak Precise 1.60 (Signet)
Kodak Precise 1.67 (Signet)
Kodak Precise TLX1.6 (Signet)
Kodak Precise Trivex (Signet)
Kodak Precise Short (Signet)
Navigator Precision (Signet)
Navigator Precision 1.56 (Signet)
Navigator Precision 1.60 (Signet)
Navigator Short (Signet)
Navigator Short 1.56 (Signet)
PE II (Signet)
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Access (Sola)
Compact ULTRA (Sola)
Compact ULTRA 1.67 (Sola)
Percepta (Sola)
Percepta Spectralite 1.54 (Sola)
Percepta Finalite 1.60 (Sola)
Solamax (Sola)
Solamax Spectralite 1.54 (Sola)
SolaOne (Sola)
SolaOne Finalite 1.60 (Sola)
SolaOne 1.67 (Sola)
Synchrony (Sola)
Synchrony 1.67 (Sola)
VIP (Sola)
VIP Spectralite 1.54 (Sola)
Visuality (Sola)
Visuality Spectralite 1.54 (Sola)
XL (Sola)
XL Spectralite 1.54 (Sola)
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Comfort (Varilux)
Comfort 1.60 (Varilux)
Comfort 1.67 (Varilux)
Ellipse (Varilux)
Ellipse 1.60 (Varilux)
Ellipse 1.67 (Varilux)
Ipseo (Varilux)
Ipseo 1.67 (Varilux)
Ipseo 1.74 (Varilux)
Liberty (Varilux)
Panamic (Varilux)
Panamic 1.67 (Varilux)
Panamic 1.74 with Crizal Alizé (Varilux)
Physio (Varilux)
Physio 1.60 (Varilux)
Physio 1.67 (Varilux)
Physio 1.74 (Varilux)
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Outlook (Vision-Ease)
Illumina (Vision-Ease)
Varivue (Vision-Ease)
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Freedom 5 (X-Cel)
Freedom Fashion Fit (X-Cel)
Freedom ID (X-Cel)
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Image (Younger)
Image 1.53 Trilogy (Younger)
Image 1.56 Easy Lite (Younger)
Image 1.67 (Younger)
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Business (Zeiss)
Gradal Brevity (Zeiss)
Gradal Brevity 1.67 (Zeiss)
Gradal Individual 1.6 (Zeiss)
Gradal Individual 1.67 (Zeiss)
Gradal RD (Zeiss)
Gradal Shorti 1.6 (Zeiss)
Gradal Top (Zeiss)
Gradal Top 1.60 (Zeiss)
Gradal Top 1.67 (Zeiss)
GT2 (Zeiss)
GT2 1.67 (Zeiss)
*
Lens Material:
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Plastic / CR-39
Glass
Mid Index
High Index
Polycarbonate
Trilogy (Trivex Aspheric)
Glass Color/Photochromatic:
(Clear)
Autumn Gold
Didynium
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)
Tan 3
Unisol
Yellow
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PhotoGray Extra (PGX)
Photobrown Extra (PBX)
PhotoSun 2
Thin & Dark Gray
Thin & Dark Brown
Photochromatic:
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Transition Gray
Transition Brown
SunSensors Gray
Sunsensors Brown
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Drivewear: Transition Polarized
Polarized:
-----------------------------------------------------
Polarized Gray 1
Polarized Gray 3
Polarized Brown 1
Polarized Brown 3
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Drivewear: Transition Polarized
Edge:
Standard
Polish
Roll
Roll and Polish
Grind:
Standard
Thin 1.0
Safety
Slab-Off
Lab Tint:
(Sample to Match)
(See Comments)
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
Fade
Coatings:
Scratch Resistant Coating
UV-400 (Ultra Violet Filter)
Titan
Titan Plus
Crizal
Crizal Alize
Tuff Kote
Other Coats:
Frame Information:
Frame Name:
Eye Size:
DBL:
B
ED
Circumference
Temple Length:
Frame Color:
( If we will be supplying a frame please specify the “Frame Color” you need )
Frame Type:
Metal
Plastic
Rimless Groove
Rimless Drill
*
Frame Status:
Frame To Come
Lens Only
Lab Supply Frame
Pattern To Come
Uncut
3.0 Industrial or Sport Frame
Additional Instructions or Comments:
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