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Boston Eyes Order Form

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Gen Info: Lens: Lens:
PATIENTS NAME*
Practice Name *
Email Address*
(for copy)
   
Type: Material:

 

Prescription:

SPH (od): CYL (od): AXIS (od):
SPH (os): CYL (os): AXIS (os):
           
ADD (od): PRISM (od): BASE (od):
ADD (os): PRISM (os): BASE (os):
           
SGHT (od): PDD (od): PDN (od):
SGTH (os): PDD (os): PDN (os):

 

Frame Type:

Manufacturer:
Frame Name:
A:
B:
ED:
DBL:
Frame Material:
Special Instructions:
Message:

 

 

Pack:

Choose:

 

Tint:

Density:
Gray:
Blue:
G-15:
Solid:
Double Gradient:
Brown:
Gradient:
Other:

 

Special Treatments:

Edge:
Polish:
Roll and Polish:
Polarized:
Transition:
Slab Off:
UV Coating:
SR Coating:
Mirror Coating:
Claris:
Sharp View:
Zeiss:
Other: