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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
SINGLE VISION
BIFOCAL
VARIFOCAL
SPECIAL
Yes
No
BROWN
GREY
GREEN
GREY/GREEN
GREY/GREEN
YELLOW
BLUE
PINK/RED
SPECIAL
10%
30%
50%
70%
85%
Coating
Polarised
HI Index
Transition
H/C
MAR
MAR+
Other
BROWN
GREY
GREY/GREEN
BLUE SKY
BLUE INK
VIOLET
BLUE PURPLE
BROWN GRAD
GREY GRAD
GREY/GREEN GLAD
1.53
1.59
1.6
1.67
1.74
GREY
BROWN
GREY/GREEN
AMBER
AMETHYST
EMERALD
SAPPHIRE
Sphere
Cyl
Axis
Add
Prism
R
UP
DOWN
IN
OUT
L
UP
DOWN
IN
OUT
P.D.
Mono
*
Height
Engrave
Engrave Details
R
L
Is Nearest Centration Acceptable ?
Yes
No
Frame Details
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ECOLINE
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HERO
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JCB
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PLANET+
PS
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ZENITH
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Model
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A
B
ED
D.B.L
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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
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