Order Form General Date: * Patient: * Email: * Account #: * Name: * Phone: * Selections GP Designs: * Please Select Spherical Bi-Toric Back Toric Front Toric Aspheric Polycon II iSee Fargo GOV CRT GP Express DMP-Doctor's Myopia Prevention ACL Cone Soper Cone McGuire Rose-K Dyna-Z Target Nulife Trio iSight Scleral iSight Semi-Scleral ALS-Alignment Series Soft Lens Designs: * Please Select iSight Sphere iSight-Toric iSight-Aphakic iSight-Multifocal-Center Distance iSight-Multifocal- Center-Near iSight-Toric Multifocal-Center Distance iSight-Toric Multifocal- Center-Near iSight-Bifocal-Center Distance iSight-Bifocal- Center-Near iSight-Toric Bifocal-Center Distance iSight-Toric Bifocal- Center-Near BioCurve-Sphere BioCurve- Toric BioCurve- Aphakic Yamakone Warranty: * Please Select Easy Fit Easy Fit Remake New Soft Lens Order Soft Lens Exchange Material: * Please Select Paragon Vision Sciences Fluoroperm 30 Fluoroperm 92 Fluoroperm 151 Optacryl 60 Paragon HDS Paragon HDS 100 Paraperm 02 Paraperm EW Paragon Thin Paragon High Index Polymer Technology Boston II Boston IV Boston VII Boston Equalens II Boston ES Boston EO Boston XO Boston XO2 Equalens Envision Contamac Optimum Classic Optimum HR 1.51 Optimum HR 1.53 Optimum Comfort Optimum Extra Optimum Extreme Hybrid FS Additional Materials Fluorex 300 Fluorex 500 Fluorex 700 SGP I SGP II SGP 3 PMMA TYRO-97 SA-18 SA-32 ONSI-56 HYDRO-2 FLOSI Soft Lenses Methafilcon A Hioxifilcon A (Gold Series) Efrofilcon A (SiHy) OD - Right COLOR B.C. POWER DIAMETER OPTICAL ZONE 1 PC W 2 PC W 3 PC W 4 PC W 5 PC W 6 PC W 7 PC W CENTER THICKNESS A.E.I OS - Left COLOR B.C. POWER DIAMETER OPTICAL ZONE 1 PC W 2 PC W 3 PC W 4 PC W 5 PC W 6 PC W 7 PC W CENTER THICKNESS A.E.I Add-Ons Add-Ons Selected Please Select Plasma Treat Dot Lenticular Aspheric Panafocal Prism Myodisc K readings and Spectacle Refraction OD K's : / K's2 : X K's3 : SRX : / SRX2 : X SRX3 : OS K's : / K's1 : X K's2 : SRX : / SRX2 : X SRX3 : Instructions Instructions Provided
