MH Optical

Account Information

Note: Red fields are required.

Acct Name/Location

Account #

Mailing Address
(If blank, will mail to address on file)

Phone Number

E-Mail Address

Contact Person

Patient Info

Patient Name

Tray

Frame

A	B	ED	DBL

Frame Eye Size

FrameName

To Follow Supply Call When Ready Uncut

FrameManufacture

Frame Color

FrameType

Metal Zyl Nylor Drill

SPH

CYL

AXIS

PRISM

BASE

OC HGT

ADD

SEG HT

DIST/
DPD

NEAR
PD

TOT DEC

Lenses

Treatments Y / N
RLX/SS.....
Foundation.
UV.............

Photochromic
or Polarized
Grey......... Brown
Transition..
SunSensor
InstaShade
Polarized...
PGX.........
None..............

Material
(Select One)
CR39
CR39 RLX/SS
1.56
1.60
1.66
1.67
Polycarbonate
Spectralite
Trivex
Glass

Type . . . . . . . .
(Select One)
SV
FT 28
FT 35
Round 22
Executive
Blended
TriFocal 7x28
TriFocal 8x35
VIP

. . . . . . . . . . . . . .
Exceed
--- ( EZ Fit )
Exceed Mini
--- ( EZ Fit Mini )
Varsity
Outlook
Proceed
Proceed II
Sola MAX
Adaptar
Other-Specify

. . . . . . . . . . . .
Concise
Precise
Unique
Gradal
Brevity
Compact
Natural
Image
Fusion
Comfort
Picilo

AR/Coating
Alize
Super ET
Gold ET
Granite
Carat Advantage
Kodak CleAR
No AR

. . . . . . . . . . . . . . . .
Cool Blue Mirror
Cool Silver Mirror
Cool Gold Mirror
No Mirror Coating

Tint
None
Gradient
Solid
Percent
Color.........

Special Instructions

Shipping Information

Route
Network
PDS

AirBorne
UPS
Pick Up

Metro
On File