Midwest Lens - Web Order Form
(
*
red asterisk denotes required field )
*
Account Number:
*
Pair
Right Only
Left Only
Patient Last Name:
Patient First Name:
Medicaid Job
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:
Single Vision
Aspheric Single Vision
Aspheric Lenticular Single Vision
Tegra Aspheric Single Vision
-----------------------------------------------------
FT 25
FT 28
FT 35
FT 45
Round 22
Round 24
Round 25
Executive Bifocal
Aspheric Lenticular FT 22
Aspheric Lenticular Round 22
Executive CRT Trifocal
Curve Top 28
Curve Top 40
Occupational FT 25
Occupational FT 28
Occupational FT 35
Occupational Exec
Occupational Round 22
Tegra Aspheric FT 28
Ultex Bifocal
-----------------------------------------------------
7x25
7x28
7x35
8x35
10x35
12x35
14x35
Executive ED Trifocal
Executive Trifocal
Quadrifocals 7x25
Quadrifocals 7x28
-----------------------------------------------------
Progressive
Progressive Style:
Compact (AO)
Easy (AO)
-----------------------------------------------------
Centurion (Augen)
Centurion Short (Augen)
Trinity (Augen)
Trinity Short (Augen)
-----------------------------------------------------
Accolade (Essilor)
Adaptar (Essilor)
Definity (Essilor)
Definity Short (Essilor)
Natural (Essilor)
Ovation (Essilor)
SmallFit (Essilor)
-----------------------------------------------------
Amplitude (Hoya)
Amplitude Mini (Hoya)
GP Wide (Hoya)
LifeStyle (Hoya)
Summit CD (Hoya)
Summit ECP (Hoya)
-----------------------------------------------------
Hyperview (Optima)
-----------------------------------------------------
AF (Pentax)
AF Mini (Pentax)
Diamond Clear (Pentax)
-----------------------------------------------------
Proceed (Seiko)
Proceed II Short (Seiko)
Proceed III Super Short (Seiko)
-----------------------------------------------------
Genesis Attitude (Shamir)
Piccolo Attitude (Shamir)
Autograph (Shamir)
Creation (Shamir)
Autograph 1.67 (Shamir)
Genesis (Shamir)
Office (Shamir)
Piccolo (Shamir)
-----------------------------------------------------
ShoreView (Shore)
ShoreView Mini (Shore)
-----------------------------------------------------
Kodak (Signet)
Kodak Concise (Signet)
Kodak Precise (Signet)
Kodak Precise Short (Signet)
Navigator (Signet)
Navigator Short (Signet)
Unique (Signet)
-----------------------------------------------------
Access (Sola)
Compact ULTRA (Sola)
Solamax (Sola)
SolaOne (Sola)
VIP (Sola)
-----------------------------------------------------
Comfort (Varilux)
Comfort 360 (Varilux)
Ellipse (Varilux)
Ellipse 360 (Varilux)
Ipseo (Varilux)
Panamic (Varilux)
Physio (Varilux)
Physio 360 (Varilux)
Physio 360 Short (Varilux)
-----------------------------------------------------
Outlook (Vision-Ease)
Illumina (Vision-Ease)
Premir Plus (Vision-Ease)
Tegra Outlook (Vision-Ease)
Varivue (Vision-Ease)
-----------------------------------------------------
Freedom 5 (X-Cel)
Freedom ID (X-Cel)
-----------------------------------------------------
Image (Younger)
Image Wrap (Younger)
-----------------------------------------------------
Gradal Brevity (Zeiss)
Gradal Individual (Zeiss)
Gradal RD (Zeiss)
Gradal Top (Zeiss)
GT2 (Zeiss)
GT2 3D (Zeiss)
GT2 3D Short (Zeiss)
*
Lens Material:
-----------------------------------------------------
Plastic
Plastic 1.56
Plastic 1.60
Plastic 1.66
Plastic 1.67
Plastic 1.70
Plastic 1.74
Polycarbonate
Trivex
Spectralite
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:
-----------------------------------------------------
Transition Gray
Transition Brown
SunSensors Gray
Sunsensors Brown
-----------------------------------------------------
Drivewear: Transition Polarized
Polarized:
-----------------------------------------------------
Polarized Gray 1
Polarized Gray 3
Polarized Brown 1
Polarized Brown 3
-----------------------------------------------------
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)
Tuff Kote
AR Coatings:
TitanAR
TitanAR Plus
Crizal Alize
Crizal Avance with Scotchgard
Super HiVision
Teflon Clear Coat
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 frame color
)
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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