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