GET ALL YOUR QUESTIONS ANSWERED QUICK! LIVE CHAT OR CALL US AT 1-855-828-0122, EXT 1
0
Shopping Cart
Home
Membership
Twelve84
About
Contact
My Account
Menu
Menu
Order Form v2
"
*
" indicates required fields
Patient
Patient
First Name
Last Initial
ID #
Shipping
Ship To Patient Checkbox
Ship to patient
Ship To Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Prescription
OD Sph
OD Cyl
OD Axis
OD Add Power
OS Sph
OS Cyl
OS Axis
OS Add Power
OD Horizontal Prism Value
OD Horizontal Prism Direction
BI
BO
OD Vertical Prism Value
OD Vertical Prism Direction
BU
BD
OS Horizontal Prism Value
OS Horizontal Prism Direction
BI
BO
OS Vertical Prism Value
OS Vertical Prism Direction
BU
BD
OD PD
Number only
OS PD
Number only
Hidden
For Alignment
Hidden
For Alignment
OD Seg Height/OC Height
Number only
OS Seg Height/OC Height
Number only
Hidden
For Alignment
Hidden
For Alignment
Frame
Style/Color
*
Adelaide - Blackbird - 100
Adelaide - Brown Barrel - 217
Adelaide - Wild Berry - 504
Aden - Blackbird -100
Aden - Stout Brown -204
Alexandria - Dust Jacket -710
Alexandria - Mariout -409
Alexandria - Ruby Sands -609
Aruba - Dive Site -4008
Aruba - Reef -8012
Aruba - Rosy Glow -9003
Asheville - Blackbird -100
Asheville - Smokey Mountain -706
Asheville - Smore -218
Athens - Loam - 8008
Athens - Medeterranian Sunset - 2002
Athens - Silver Coin - 8003
Auckland - Cobblestone -3004
Auckland - Garden Gate -1004
Auckland - Skyscraper -8009
Austin - Brown Barrel -217
Austin - Texas Charcoal -702
Austin - Toffee -208
Basel - Gargoyle -700
Basel - Neptune -305
Basel - Woodblock -223
Berkeley - Ironwork -1003
Berkeley - Park Bench -3007
Berkeley - Tidepool -4006
Bristol - Blackbird -100
Bristol - Midnight -304
Bristol - Olive -405
Burlington - Hunter -108
Burlington - Soldier -708
Burlington - Whisky -214
Calgary - Berry Patch -501
Calgary - Hidden Oyster -212
Calgary - Sky -303
Charlotte - Chestnut - 201
Charlotte - Moss - 401
Charlotte - Raisin - 503
Chicago - Blue Hour -4000
Chicago - Garden Gate -1004
Chicago - Salted Caramel -3002
Cholula - Austrian Pine -402
Cholula - Cabarnet -607
Cholula - Red Leather - 606
Darwin - Black Tie - 1001
Darwin - Microscope Grey - 8000
Darwin - Sunrise Gold - 2000
Dublin - Chocolate -3006
Dublin - Gunmetal -8001
Dublin - Onyx -1002
Elizabeth - Biltmore Tort - 219
Elizabeth - Jacaranda - 505
Elizabeth - Merlot -605
Florence - Black Falcon - 704
Florence - Italian Sunset - 500
Florence - Piazza - 203
Geneva - Blue Lake -4002
Geneva - Golden Sun - 2001
Geneva - Silver Coin -8003
Geneva - Unique Pink -9000
Hamilton - Ironwork -1003
Hamilton - Stony Creek -8005
Hamilton - Waterfall -4001
Hartford - Deep Waters -4005
Hartford - Gunmetal -8001
Hartford - Newsprint -8002
Hartford - Sunrise Gold - 2000
Havana - Cigar Wrap - 202
Havana - Palm Tree - 404
Havana - Tobacco - 102
Helena - Blackbird - 100
Helena - Feldspar Grey - 703
Helena - Malachite - 213
Houston - Angus Black - 106
Houston - Rocket Ship Grey - 707
Houston - Whisky - 214
Ibiza - Dahlia -506
Ibiza - Sea Spray -407
Ibiza - Starry Night -109
Key West - Bronze -3008
Key West - Wrought Iron -8010
Kingston - Black Steel -1005
Kingston - Bluebird -4004
Kingston - Nutmeg -3005
Kobe - Brown Beetle -216
Kobe - East Sea -300
Kobe - Well-done -107
Larissa - Purple Orchid -6000
Larissa - Silver Coin -8003
Larissa - Unique Pink -9000
Lincoln - Blue Hour -4000
Lincoln - Ironwork -1003
Lincoln - Stony Creek -8005
Lisbon - Coastal Blue -4003
Lisbon - Mediterranean Sunset -2002
Lisbon - Silver Coin -8003
London - Newcastle Brown - 2003
London - Tidepool -4006
Lyon - Café au Lait -225
Lyon - Drapeau -306
Lyon - Florentine -408
Madison - Berry Patch - 501
Madison - Branch -103
Madison - Hidden Oyster - 212
Madrid - Blackbird -100
Madrid - Iguana -406
Madrid - Smokey Mountain -706
Mallorca - Baltic Sea -4007
Mallorca - Cliff Face -8011
Mallorca - Sunset -9002
Miami - Magenta -9001
Miami - Palm Frond -1100
Miami - Sea Salt -5000
Milan - Blush -608
Milan - Carribbean -410
Milan - Leather -220
Montreal - Cardinal - 604
Montreal - Gentry Brown - 215
Montreal - Purple Dawn - 104
Munich - Coastal Oak -210
Munich - Heather - 700
Munich - Stout Brown -204
Nashville - Ironwork -1003
Nashville - Salted Carmel -3002
Nashville - Waterfall -4001
Oakland - Black Tie -1001
Oakland - Italian Clay -3000
Oakland - Microscope Grey - 8000
Oxford - Blackbird -100
Oxford - Ivy -403
Oxford - Whisky -214
Perth - Ironwork -1003
Perth - Porter -3003
Perth - Shiraz -7000
Portland - Crystal -901
Portland - IPA -222
Portland - Misty Morning -320
Prague - Aged Brick -221
Prague - Crystal -901
Prague - Midnight -304
Salem - Black Hat -101
Salem - Chestnut -209
Salem - Scarlet -601
Salzburg - Blue Hour -4000
Salzburg - Garden Gate -1004
Salzburg - Tin Roof -8007
Sanya - Banyan Bark - 206
Sanya - Plum Blossom - 502
Sanya - White Sand - 800
Savannah - Georgia Rose -600
Savannah - Live Oak - 205
Savannah - Magnolia Leaf - 400
Sofia - Blackbird - 100
Sofia - Chestnut -201
Sofia - Plum Blossom -502
Sydney - Ironwork - 1003
Sydney - Purple Orchid - 6000
Sydney - Salted Caramel - 3002
Toronto - Hazelnut -3001
Toronto - Ironwork -1003
Toronto - Stony Creek -8005
Tulum - Cenote -307
Tulum - Coconut -226
Tulum - El Castillo -110
Venice - Black Swan -105
Venice - Espresso -200
Venice - Ventian Wine -603
Verona - Black Olive - 1000
Verona - Current -7001
Verona - Italian Clay -3000
Victoria - Austrian Pine -402
Victoria - Maple -207
Victoria - Rosebud Red -602
Vienna - Blackbird -100
Vienna - Coastal Blue -301
Vienna - Lipizzan Brown -211
Waikiki - Austrian Pine -402
Waikiki - Carribean -410
Waikiki - Hydrangea -510
York - Earl Grey -8004
York - Garden Gate -1004
York - Porter -3003
Lenses
Discover or Inspire
*
Discover
Inspire
Focal Type
*
Single Vision
Flat Top 28 (Only Discover)
Progressive
Material
*
CR-39 Plastic
Polycarbonate
Trivex (Inspire Only)
1.60 Hi Index (Inspire Only)
1.67 Hi Index (Inspire Only)
Lens Color
*
Clear
Photochromatic Grey
Photochromatic Brown
Polarized Grey (No FT-28)
Polarized Brown (No FT-28)
Anti-Reflective Coating
*
Standard (All Discover Packages)
Top Level (Inspire Package Only)
Top Level w/ Blue Light (Inspire Package Only)
Additional Order Information
Reference #
Lab Instructions
Remake Information (optional)
Is Remake
This order is a remake
Remake Reason
Prescription Change
Lab Error
Optician Error
Patient Restyle
Non-Adapt to Progressive
Non-Adapt to Material
Measurement Change
Warranty - Scratch/Hard Coating
Warranty - AR Coating
Warranty - Drill Mount/3 piece
Remake Note
Hidden
User Login
Hidden
User Email
Scroll to top
Optical-X
Choice Shipping Address
×