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:      
Left Eye: Prism:    
Right Eye: Add: Seg Height: OC: Base Curve:
Left Eye: Add: Seg Height: OC: Base Curve:

* Lens Style:
Progressive Style:
* Lens Material:
Glass Color/Photochromatic:
Photochromatic:
Polarized:

Edge:
Grind:
Lab Tint:
Tint Type:

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:
* Frame Status:
3.0 Industrial or Sport Frame
Additional Instructions or Comments:

         
 

 


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