| DEFAULT REASON FOR REQUEST |
CONTACT LENS RX:
EDGE:
-------------------------------------------------------------------------
MFG: LENS TYPE:
TINT: DOT:
-------------------------------------------------------------------------
[] D.W. [] E.W. [] Mono
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ISSUING INSTRUCTIONS:
[] See DR. for Dispensing
Right Left
[] Dispense Only
[] Replacement
[] Needs I&R
[] Kit Training
[] Reinstruct
[] Other (Describe)
-------------------------------------------------------------------------
DELIVERY INSTRUCTIONS: [] Veteran [] VA Medical Center
EYEGLASS REPLACEMENT: [] Lost [] Broken [] Stolen
Base:
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####### (Information Below - to be completed by Prosthetics #########
ORDERING INFORMATION
Obligation #:
Total Cost:
VISA #:
EXP DATE:
AUTHORIZATION SIGNATURE: ____________________________
Power:
DIA:
OZ:
Thick:
SEC:
PER:
|
