OPTURA GLAZING LIMITED

Simple Silacon Glasses Price: $59 Qty: 01
Simple Easin Glasses Price: $20 Qty: 02
Simple Macrox Glasses Price: $320 Qty: 03

Total: $120

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Order Form

Date

Patient Ref.

Form & Type of Lens

Tint (ABS %)

Extras

Yes No

Coating	Polarised	HI Index	Transition

	Sphere	Cyl	Axis	Add	Prism
R
L

P.D.		Mono *	Height	Engrave Engrave Details
	R
	L			Is Nearest Centration Acceptable ? Yes No

Frame Details

Model	Colour	A	B	ED	D.B.L

Special Instruction :

Cancel

Date

Patient Ref.

Form & Type of Lens

TINT (ABS %)

EXTRAS

	Sphere	Cyl	Axis	Add	Prism
R
L

P.D.		Mono	Height	ENGRAVE ENGRAVE DETAILS
	R
	L			Is Nearest Centration Acceptable ?

Frame Details

Model	Colour	A	B	ED	D.B.L

Special Instruction :