2321 Welcome Ave., Richmond, CA 94804 | Office 510.232.3076 Fax 510.232.3074

CensorMe

For RX ONLY

ACCOUNT

ACCOUNT PHONE NUMBER



DATE
PATIENT NAME JOB #

DO YOU HAVE THE POWER?

  SPHERE CYLINDER AXIS PRISM ADD
OD
OS
PD SLAB OFF SEG. HT./OC

IF OTHER, ENTER OTHER SEG TYPE:

ASPHERIC PLEASE
DIGITAL DESIGN

TINT COLOR 1 2 3 SOLID FADE MATCH POLARIZED

LENS TREATMENTS AR COATINGS


IF OTHER, ENTER OTHER AR COATING
EDGE TREATMENT
FRAME EYESIZE/DBL /  
ENCLOSED TO COME DROP SHIPPED TO BA
A= B= ED= THIS IS A CUSTOM / MODIFIED SHAPE
UNCUT
LENSES ONLY / NO FRAME
ARCHIVE SHAPE
Wrap Frame Vertex Panto Angle
DemoBase Curve

CHECK HERE IF THIS IS A REDO

ORIGINAL ORDER DATE
REASON
Old Lenses Enclosed
Credit Old Lenses on Return Later (COR)

WHAT MORE COULD YOU WANT?



 



HOME | CONTACT US | SHORT ORDER | NEW ACCOUNT REQUEST