Contact lens ordering form

CLIENT CODE*
E-MAIL*
PATIENT NAME*

Please remember that your Patient´s name will be printed in the Lens pack. If you prefer not to print it, just tick this box:
NEW PATIENT?

CHOOSE YOUR EYE
Right eye

Left eye

CHOOSE YOUR LENS
CHOOSE YOUR GEOMETRY

DOMINANT?

Right eyeLeft eye
Right eye

Left eye

HVID
K-READINGS
K1
K2
K1
K2
ECCENTRICITY
Right eye

Left eye

SPHERE
CYLINDER
AXIS
ADDITION
VERTEX DISTANCE
Right eye

Left eye

TOPOMAP IMAGE
Max file size: 1Mb
Format: .jpg & .png


ORDER TYPE

CHOOSE YOUR EYE
Right eye
Left eye
DIAMETER
BASE CURVE
OVERREFRACTION

SPH

CYL

AXES

SPH

CYL

AXES

AXIS LOCATION

ADDITIONAL INFO


CHOOSE YOUR EYE
Right eye

Left eye

PACK TYPE
INFORMATION ABOUT PACK

In order to specify the lens parameters you would like to use, please input the date you received / ordered the succesful trial lens

ORDER DATE

RECEIVED DATE

CLIENT CODE

EMAIL

PATIENT REFERENCE

In order to specify the lens parameters you would like to use, please input the date you received / ordered the succesful trial lens

ORDER DATE

RECEIVED DATE

CLIENT CODE

EMAIL

PATIENT REFERENCE

FIRST PACK DATE

Type any question or doubt here…