Contact Lens Order

DEMOGRAPHICS INFORMATION
Date of Service
Optician
Provider
Patient Name
Date of Birth
Phone
*Note: DX = Diagnostic or Trial Lenses
Manufacturer & Brand of Contact
Box or Qty
Price Each
Total
Base Curve
Sphere
Cylinder
Axis
Add
Diameter
Color
V-Code
Diagnosis
COPY

Manufacturer & Brand of Contact
Box or Qty
Price Each
Total
Base Curve
Sphere
Cylinder
Axis
Add
Diameter
Color
V-Code
Diagnosis
INSURANCE INFORMATION

Insurance

Auth #

Insurance Benefit
Total Before Insurance
Patient Cost
Patient Paid
Notes
Click On "Copy to Clipboard" Button to fill out the Copy Box and Capture the data for EMA!