Order Now ONLINE FITTING CALCULATOR MYENNOVY
MYENNOVY ACADEMY
Change Region
logo Academy

Contact lens ordering form

    CLIENT CODE(*)

    E-MAIL (*)

    PATIENT REFERENCE (*)

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

    NEW PATIENT? (*)

    [group group-new-patient]

    CHOOSE THE EYE

    [group dominance]
    [/group]

    [group right-eye-chosen]Right eye[/group]

    [group left-eye-chosen]Left eye[/group]

    CHOOSE YOUR LENS

    [group right-eye-chosen][/group]

    [group left-eye-chosen][/group]

    CHOOSE YOUR GEOMETRY

    [group right-eye-chosen]
    [group jad-right-geom][/group]
    [group srx-right-geom][/group]
    [group xt-right-geom][/group]
    [group g59-right-geom][/group]
    [group bg-right-geom][/group]
    [group bk-right-geom][/group]
    [/group]

    [group left-eye-chosen]
    [group jad-left-geom][/group]
    [group srx-left-geom][/group]
    [group xt-left-geom][/group]
    [group g59-left-geom][/group]
    [group bg-left-geom][/group]
    [group bk-left-geom][/group]
    [/group]

    [group dominance]DOMINANT?[/group]

    [group dominance]NoneRight eyeLeft eye
    [/group]

    [group right-eye-chosen]Right eye[/group]

    [group left-eye-chosen]Left eye[/group]

    HVID

    [group right-eye-chosen][/group]

    [group left-eye-chosen][/group]

    K-READINGS (millimeters)

    [group right-eye-chosen]K1(mm)Axis[/group]

    [group right-eye-chosen]K2(mm)Axis[/group]

    [group left-eye-chosen]K1(mm)Axis[/group]

    [group left-eye-chosen]K2(mm)Axis[/group]

    ECCENTRICITY

    [group right-eye-chosen][/group]

    [group left-eye-chosen] [/group]

    [group right-eye-chosen]Right eye[/group]

    [group left-eye-chosen]Left eye[/group]

    SPHERE

    [group right-eye-chosen][/group]

    [group left-eye-chosen][/group]

    CYLINDER

    [group right-eye-chosen][group right-mft][/group][/group]

    [group left-eye-chosen][group left-mft][/group][/group]

    AXIS

    [group right-eye-chosen] [group right-mft-ax][/group][/group]

    [group left-eye-chosen] [group left-mft-ax][/group][/group]

    ADDITION

    [group right-eye-chosen][group right-mft-ad][/group][/group]

    [group left-eye-chosen][group left-mft-ad][/group][/group]

    VERTEX DISTANCE

    [group right-eye-chosen][/group]

    [group left-eye-chosen][/group]

    [group right-eye-chosen]Right eye[/group]

    [group left-eye-chosen]Left eye[/group]

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

    [group right-eye-chosen][/group]

    [group left-eye-chosen][/group]

    [/group]


    [group group-old-patient]

    ORDER TYPE

    [group group-diagnostic-type]

    CHOOSE YOUR EYE

    [group right-eye-diagnostic]Right eye[/group]

    [group left-eye-diagnostic]Left eye[/group]

    WHAT DO YOU WANT TO CHANGE?

    [group right-eye-diagnostic][/group]

    [group left-eye-diagnostic][/group]

    DIAMETER

    [group right-eye-diagnostic][group right-eye-diagnostic-diameter] [/group][/group]

    [group left-eye-diagnostic] [group left-eye-diagnostic-diameter] [/group][/group]

    BASE CURVE

    [group right-eye-diagnostic][group right-eye-diagnostic-basecurve][/group][/group]

    [group left-eye-diagnostic][group left-eye-diagnostic-basecurve][/group][/group]

    OVER REFRACTION

    [group right-eye-diagnostic][group right-eye-diagnostic-overr]
    [group scar_chosen]

    SPH

    CYL

    AXES

    [/group]
    [group mfr_chosen][/group]
    [/group]

    [group left-eye-diagnostic]
    [group left-eye-diagnostic-overr]

    [group scal_chosen]

    SPH

    CYL

    AXES

    [/group]
    [group mfl_chosen][/group]
    [/group]
    [/group]

    AXIS LOCATION

    [group right-eye-diagnostic]
    [group right-eye-diagnostic-axis-location]

    [group xnr_chosen][/group]
    [group xtr_chosen][/group]
    [/group]
    [/group]

    [group left-eye-diagnostic]
    [group left-eye-diagnostic-axis-location]

    [group xnl_chosen][/group]
    [group xtl_chosen][/group]
    [/group]
    [/group]

    ADDITIONAL INFO

    [/group]


    [group group-pack]

    CHOOSE YOUR EYE

    [/group]

    [group right-eye-pack]Right eye[/group]

    [group left-eye-pack]Left eye[/group]

    PACK TYPE

    [group right-eye-pack][/group]

    [group left-eye-pack][/group]

    INFORMATION ABOUT PACK

    [group right-eye-pack]
    [group right-eye-first-pack-chosen]

    In order to specify the Lens parameter you would like to use, please input the date you either received or ordered the successful trial Lens.

    ORDER DATE

    RECEIVED DATE

    [/group]
    [group right-eye-replacement-chosen]

    You are repeating your last revenue order in our system for this patient.

    [/group]
    [/group]

    [group left-eye-pack]
    [group left-eye-first-pack-chosen]

    In order to specify the Lens parameter you would like to use, please input the date you either received or ordered the successful trial Lens.

    ORDER DATE

    RECEIVED DATE

    [/group]
    [group left-eye-replacement-chosen]

    You are repeating your last revenue order in our system for this patient.

    [/group]
    [/group]

    [group group-first-pack-chosen]

    FIRST PACK DATE


    Type any question or doubt here…

    [/group]
    [/group]

    [/group]

    FINAL COMMENTS

    (*) - Mandatory fields