MH Optical Supplies

Account Information

Acct Name/Location:

Account # (Required)

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

Phone Number:

E-Mail Address:

(Required)

Contact Person:

Patient Info

Patient Name:

Tray

Frame

A	B	ED	DBL

Frame Eye Size:

Frame Name:

To Follow Supply Uncut

SPH

CYL

AXIS

PRISM

BASE

OC HGT

ADD

SEG HT

DIST/
DPD

NEAR
PD

TOT DEC

Lenses

Treatments Y / N
RLX/SS.....
Foundation.
UV.............

Photochromic
or Polarized
Grey......... Brown
Transition..
SunSensor
InstaShade
Polarized...
Photochromic
None..............

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

Type . . . . . . . .
(Select One)
SV
FT 28
FT 35
Round 22
Executive
Blended
TriFocal
VIP

. . . . . . . . . . . . . .
Exceed
Exceed Mini
Varsity
Varsity Mini
Outlook
Proceed
Proceed II
Sola MAX
Succeed
Succeed Ws
Adaptar
Other-Specify

. . . . . . . . . . . .
Concise
Precise
Gradal
Brevity
Compact
Natural
Image
Fusion
Comfort

Zeiss AR/Coating
Gold ET
Super ET
Carat Advantage
Granite Hard/Slick AR
Kodak CleAR
No AR

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

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

Special Instructions:

Shipping Information:

Route
Network
PDS

AirBorne
UPS
Pick Up

Speedy
On File