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DEMOGRAPHICS
DOS:  
Provider:  
Diagnosis:
OD
OS
OU
Patient Name:
DOB:  

Show Common Lens Selection Options

LENS OPTIONS
Lens Style
Material
Coating
Transitions
Polarized / Tints
Edge Polishing
PRESCRIPTION
Acuity
Sphere
Cylinder
Axis
Dist. PD
Near PD
PRISM
AMOUNT
IN & OUT
AMOUNT
UP & DOWN
R
L

R
L
O.C. Height
Base Curve
Index
Lens Information:
OD Sphere:
OD Cylinder:
OS Sphere:
OS Cylinder:
Total OD:
Total OS:
Lens Style:
Lens Material:
FRAME INFORMATION
Line
Manufacturer
Model
Color
Eye
B
ED
Bridge
Temple
Frame Type
Cost


Frame Company Rep:
Reference #:  
Glasses Items
V CODES
OD Cost
OS Cost
OD
OS
INSURANCE INFORMATION
Insurance
Auth #
Insurance Benefit
General Notes
Optician
Date Of Pickup
Total Amount
Estimated Out of Pocket