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