Optical Order Form - RX Account Name*To which of your locations should we have this order shipped to?[For Multi-door accounts Only]Order Date* Date Format: MM slash DD slash YYYY Contact Name*PO / Ref# / Patient Name*Contact Email* Single Vision RxSphere OD*Cylinder ODAxis ODDistance PD OD*Sphere OS*Cylinder OSAxis OSDistance PD OS*Prism ODBasePrism OSBaseProgressivesADDSeg Height / OC HeightFrameStyle*Color**GUNNAR- Supply FrameEdged Lenses OnlyLens Material*PolycarbonateTrivexHigh-Index 1.67Lens Type*SV DigitalConventional ProgressiveComputer progressive "Office"Computer Progressive "Desk"+0.25 Power Boost- Anti-Fatigue+0.50 Power Boost- Anti-Fatigue+0.75 Power Boost- Anti-FatigueLens Tint*Amber (BLPF 65)Amber Max (BLPF 98)Clear (BLPF 35)Amber-Transitions (BLPF 65/90)Clear-Transitions (BLPF 35/90)SunPrescriptionPlease upload a VALID copy of the patient's actual SIGNED prescription. Note that this document must be valid and signed and is required by US law before we can start the order.Upload a FileNotes / Comments*Double-sided A/R coating included on the lenses* Optical Order Form - RX