1724 Mandela Pkwy. #4, Oakland, CA 94607 | fax 510.452.5369 office 510.452.5367

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?



 



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