| DEFAULT REASON FOR REQUEST |
EYEGLASS RX:
[NEAR] Right Left
Sphere Cylinder:
Axis:
Prism:
Base:
BC:
MRP:
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[NEAR] Right Left
[DISTANCE] Right Left
BC:
MRP:
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[NEAR] Right Left
Addition Height:
Type:
Width:
PD Far:
PD Near:
PD Near Inset:
Sphere Cylinder:
Total Inset:
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[FRAME SELECTION]
Frame Name:
Color:
Eyesize:
Bridge Size:
Temple Length:
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[EYEWEAR OPTIONS]
Axis:
Lens Material: [] Plastic [] Glass [] Polycarb
Lens Style: [] Single Vision
[] Bifocal
[] Trifocal
[] Lenses Only
[] Safety
[] Tint*
[] Progressive*
[] Other (Description):
Prism:
*Medical Necessity (required) for Tint or Progressive:
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SPECIAL INSTRUCTIONS FOR EYEWEAR FABRICATION:
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DELIVERY INSTRUCTIONS: [] Veteran [] VA Medical Center
EYEGLASS REPLACEMENT: [] Lost [] Broken [] Stolen
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####### (Information Below - to be completed by Prosthetics #########
Base:
ORDERING INFORMATION
Obligation #:
Total Cost:
VISA #:
EXP DATE:
AUTHORIZATION SIGNATURE: ____________________________
BC:
MRP:
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|
