New Hampshire Optical

Choose Lab: - Concord, NH - Lewiston, ME.

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Account Information

Note: Red fields are required

Acct Name/Location

Account #

Mailing Address
(If blank, will mail to address on file)

Phone Number

E-Mail Address

Contact Person

Patient Info

Patient Name

Tray

FRAME

Uncut
Edge Only
Supply
2Follow
Call W/Ready

Metal
Zyl
Drill
Groove

Frame Packages ( None)
Value Line

1 2 3 4
Back to School

Jelly Bean

Mfg

Name

Eye Size

DBL

Temple

Circumference

Color

Edge Type Roll& Polish Polish Edges Regular

Wrap Frame Yes No

SPH

CYL

AXIS

PRISM

BASE

OC HGT

ADD

SEG HT

DIST/
DPD

NEAR
PD

TOT DEC

Lenses

Treatments Y / N
RLX/SS 2 Side
............1 Side ..
Foundation...
UV................

Photochromic
or Polarized
Grey......... Brown
None..............
Transition..
SunSensor
InstaShade
Polarized...
PGX.........
Thin&Dark
DriveWear
Life RX
Other-Specify

Material
(Select One)
CR39
CR39 RLX/SS
1.56
1.60
1.66
1.67
1.74
Polycarbonate
Spectralite
Trivex
Glass

Type . . . . . . . .
(Select One)
SV
FT 28
FT 35
Round 22
Executive
Blended
TriFocal 7x28
TriFocal 8x35

. . . . . . . . . . . . .

Adaptar
AO Compact
Concise
Precise
Exceed
Exceed Mini
Gradal
Gradal GT2
Image
Life XS
Natural

. . . . . . . . . . . .

Outlook
Sola VIP
Sola VIP Gold
Sola MAX
Comfort
Panamic
Physio
Other- Specify

AR Coating
No AR
Premium AR *
Carat Advantage
Crizal Alize
Crizal Alize/ Clear Guard
Kodak CleAR
Granite Hard/Slick AR
Carat
Crizal
Super ET
Gold ET
Elite
Reflection Free

* Lab choice of Carat, Crizal, Granite or CleAR to expedite service.

Mirror Coating
No Mirror Coating
Cool Blue Mirror
Cool Silver Mirror
Cool Gold Mirror
Solid Mirror
Color...

Tint
None
Gradient
Double Gradient
Solid
Percent
Color.........

Special Instructions