PEARLE VISION FAX ORDER FORM
PATIENTS INFORMATION
DAYTAG: CUSTOMER NAME:
ADDRESS: STATE: ZIP CODE:
HOME PHONE#: OTHER PHONE# TRAY #
| SPHERE | CYLINDER | AXIS | PRISM | |
| R: | ||||
| L: | ||||
| ADD ( R ): | SEG HTS : | |||
| ADD ( L ): | SEG HTS : | |||
| PD ( R ): | ||||
| PD ( L ): |
| FRAME MODEL | FRAME COLOR | ||
| FRAME SIZE | A: DBL: ED: B: | FRAME TYPE |
SINGLE VISION BIFOCAL TRIFOCAL PROGRESSIVE
SCRATCH ULTRA-VIOLET ANTI-GLARE TRANSITION POLARIZED
MIRROR POLYCARBONATE HI-INDEX 1.60 HI-INDEX 1.67
TINT (SPECIFY COLOR) @ %
