Order Form v2 "*" indicates required fields PatientPatient First Name Last Initial ID # ShippingShip To Patient Checkbox Ship to patient Ship To Address* Address Line 1 Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PrescriptionOD Sph OD Cyl OD Axis OD Add Power OS Sph OS Cyl OS Axis OS Add Power OD Horizontal Prism Value OD Horizontal Prism DirectionBIBOOD Vertical Prism Value OD Vertical Prism DirectionBUBDOS Horizontal Prism Value OS Horizontal Prism DirectionBIBOOS Vertical Prism Value OS Vertical Prism DirectionBUBDOD PD Number onlyOS PD Number onlyHiddenFor Alignment HiddenFor Alignment OD Seg Height/OC Height Number onlyOS Seg Height/OC Height Number onlyHiddenFor Alignment HiddenFor Alignment FrameStyle/Color*Adelaide – Blackbird – 100Adelaide – Brown Barrel – 217Adelaide – Wild Berry – 504Aden – Blackbird – 100Aden – Stout Brown – 204Alexandria – Dust Jacket – 710Alexandria – Mariout – 409Alexandria – Ruby Sands – 609Aruba – Dive Site – 4008Aruba – Reef – 8012Aruba – Rosy Glow – 9003Asheville – Blackbird – 100Asheville – Smokey Mountain – 706Asheville – Smore – 218Athens – Loam – 8008Athens – Mediterranean Sunset – 2002Athens – Silver Coin – 8003Auckland – Cobblestone – 3004Auckland – Garden Gate – 1004Auckland – Skyscraper – 8009Austin – Brown Barrel – 217Austin – Texas Charcoal – 702Austin – Toffee – 208Barcelona – Balearic Sea – 410Barcelona – Barri Gotic – 111Barcelona – Whisky – 214Basel – Gargoyle – 708Basel – Neptune – 305Basel – Woodblock – 223Berkeley – Ironwork – 1003Berkeley – Park Bench – 3007Berkeley – Tidepool – 4006Berlin – Blackbird – 100Berlin – Shale – 701Berlin – Whisky – 214Bristol – Blackbird – 100Bristol – Midnight – 304Bristol – Olive – 405Bruges – Blackbird – 100Bruges – Moody Sky – 705Bruges – Whisky – 214Burlington – Hunter – 108Burlington – Soldier – 708Burlington – Whisky – 214Calgary – Berry Patch – 501Calgary – Hidden Oyster – 212Calgary – Sky – 303Chicago – Blue Hour – 4000Chicago – Garden Gate – 1004Chicago – Salted Caramel – 3002Cholula – Austrian Pine – 402Cholula – Cabarnet – 607Darwin – Microscope Grey – 8000Darwin – Sunrise Gold – 2000Dublin – Chocolate – 3006Dublin – Golden Sun – 2001Dublin – Gunmetal – 8001Dublin – Onyx – 1002Dubuque – Cobblestone – 3004Dubuque – Skyscraper – 8009Elizabeth – Merlot – 605Florence – Black Falcon – 704Florence – Italian Sunset – 500Florence – Piazza – 203Geneva – Blue Lake – 4002Geneva – Golden Sun – 2001Geneva – Onyx – 1002Geneva – Silver Coin – 8003Geneva – Unique Pink – 9000Hamilton – Ironwork – 1003Hamilton – Stony Creek – 8005Hamilton – Waterfall – 4001Hartford – Deep Waters – 4005Hartford – Gunmetal – 8001Hartford – Newsprint – 8002Hartford – Sunrise Gold – 2000Havana – Cigar Wrap – 202Havana – Palm Tree – 404Havana – Tobacco – 102Helena – Blackbird – 100Helena – Feldspar Grey – 703Helena – Malachite – 213Houston – Angus Black – 106Houston – Rocket Ship Grey – 707Houston – Whisky – 214Ibiza – Dahlia – 506Ibiza – Sea Spray – 407Ibiza – Starry Night – 109Key West – Bronze – 3008Key West – Wrought Iron – 8010Kingston – Black Steel – 1005Kingston – Bluebird – 4004Kingston – Nutmeg – 3005Kobe – Brown Beetle – 216Kobe – East Sea – 300Kobe – Well-done – 107Larissa – Purple Orchid – 6000Larissa – Silver Coin – 8003Larissa – Unique Pink – 9000Lincoln – Blue Hour – 4000Lincoln – Ironwork – 1003Lincoln – Stony Creek – 8005Lisbon – Coastal Blue – 4003Lisbon – Ironwork – 1003Lisbon – Mediterranean Sunset – 2002Lisbon – Silver Coin – 8003London – Newcastle Brown – 2003London – Olivewood – 8006London – Tidepool – 4006Lyon – Café au Lait – 225Lyon – Drapeau – 306Lyon – Florentine – 408Madison – Branch – 103Madrid – Blackbird – 100Madrid – Iguana – 406Madrid – Smokey Mountain – 706Mallorca – Baltic Sea – 4007Mallorca – Cliff Face – 8011Mallorca – Sunset – 9002Miami – Magenta – 9001Miami – Palm Frond – 1100Miami – Sea Salt – 5000Milan – Blush – 608Milan – Carribbean – 410Milan – Leather – 220Montreal – Cardinal – 604Montreal – Gentry Brown – 215Montreal – Purple Dawn – 104Munich – Coastal Oak – 210Munich – Stout Brown – 204Nashville – Ironwork – 1003Nashville – Salted Carmel – 3002Nashville – Waterfall – 4001Oakland – Microscope Grey – 8000Oxford – Crystal – 901Oxford – Ivy – 403Oxford – Whisky – 214Perth – Ironwork – 1003Perth – Porter – 3003Perth – Shiraz – 7000Portland – Crystal – 901Portland – IPA – 222Portland – Misty Morning – 320Prague – Aged Brick – 221Prague – Crystal – 901Prague – Midnight – 304Salem – Black Hat – 101Salem – Chestnut – 209Salem – Scarlet – 601Salzburg – Blue Hour – 4000Salzburg – Garden Gate – 1004Salzburg – Tin Roof – 8007Sanya – Banyan Bark – 206Sanya – Plum Blossom – 502Sanya – White Sand – 800Savannah – Georgia Rose – 600Sydney – Ironwork – 1003Sydney – Purple Orchid – 6000Sydney – Salted Carmel – 3002Toronto – Hazelnut – 3001Toronto – Stony Creek – 8005Tulum – Cenote – 307Tulum – Coconut – 226Tulum – El Castillo – 110Venice – Black Swan – 105Venice – Espresso – 200Venice – Ventian Wine – 603Verona – Black Olive – 1000Verona – Current – 7001Verona – Italian Clay – 3000Victoria – Austrian Pine – 402Victoria – Azure – 308Victoria – Maple – 207Victoria – Rosebud Red – 602Vienna – Blackbird – 100Vienna – Coastal Blue – 301Vienna – Lipizzan Brown – 211Waikiki – Austrian Pine – 402Waikiki – Blush – 608Waikiki – Carribean – 410Wichita – Gunmetal – 8001Wichita – Newsprint – 8002York – Earl Grey – 8004York – Garden Gate – 1004York – Porter – 3003LensesDiscover or Inspire*DiscoverInspireFocal Type*Single VisionFlat Top 28 (Only Discover)ProgressiveOffice LensMaterial*CR-39 PlasticPolycarbonateTrivex (Inspire Only)1.60 Hi Index (Inspire Only)1.67 Hi Index (Inspire Only)Lens Color*ClearPhotochromatic GreyPhotochromatic BrownPolarized Grey (No FT-28)Polarized Brown (No FT-28)Solid Tint (Match to Key West 8010, Tulum 226, 307)Gradient Tint (Match to all Aruba, Key West 3008, Tulum 110)Mirrored Tint (Match to all Mallorca)Anti-Reflective Coating*Standard (All Discover Packages)Top Level (Inspire Package Only)Top Level w/ Blue Light (Inspire Package Only)Standard Backside (For Discover Polarized or Tints)Top Level Backside (For Inspire Polarized or Tints)Additional Order InformationReference # Lab InstructionsRemake Information (optional)Is Remake This order is a remake Remake ReasonPrescription ChangeLab ErrorOptician ErrorPatient RestyleNon-Adapt to ProgressiveNon-Adapt to MaterialMeasurement ChangeWarranty – Scratch/Hard CoatingWarranty – AR CoatingWarranty – Drill Mount/3 pieceRemake Note HiddenUser Login HiddenUser Email