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Test Demo Form
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Test Demo Form
Test Demo Form
Horizon Lens office
2020-05-14T01:21:24+00:00
New Order Form
Patient Info:
Account #:
Email
Date
Date Format: MM slash DD slash YYYY
Phone
Shipping Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Store Name:
Patient First Name
Patient Last Name
Tray# / ID#
Lens Info:
Job Type
*
Uncut
Finished
Frame to Follow
Yes
No
Pair/R/L
*
Pair of Lenses
Right lens Only
Left Lens Only
Edge Type
Bevel
Groove
Rimless
Lens Options
*
Zeiss Progressive
Zeiss Surfaced SV
Zeiss Bifocal
Horizon Progressive
Horizon Surfaced SV
Horizon Bifocal
Crizal Stock SV
Horizon Stock SV
Zeiss Stock SV
Material - Zeiss
*
CR39
Polaycarbonate
Trivex
1.60 High Index
1.67 High Index
1.74 High Index
Material - Horizon
*
CR39
Polaycarbonate
Trivex
1.60 High Index
1.67 High Index
1.74 High Index
Material - Horizon Stock
*
CR39
Polaycarbonate
Trivex
1.60 High Index
1.67 High Index
1.74 High Index
Material - Zeiss Stock
*
CR39
Polaycarbonate
Trivex
1.67 High Index
1.74 High Index
Material - Zeiss Bifocal
*
CR39
Polaycarbonate
Trivex
1.60 High Index
1.67 High Index
1.74 High Index
Material - Horizon Bifocal
*
CR39
Polaycarbonate
1.60 High Index
1.67 High Index
Coating CR39
Super Hydrophobic AR
Hydrophobic AR
Hardcoat
Uncoated
Transitions-8 Hydrophobic AR
Coating Poly
Super Hydrophobic AR
Hydrophobic AR
Blue Blocker Hydrophobic AR
Hardcoat
Transitions-8 Hydrophobic AR
Coating Trivex
Super Hydrophobic AR
Hardcoat
Coating 1.60 H.I.
Super Hydrophobic AR
Hydrophobic AR
Blue Blocker Hydrophobic AR
Hardcoat
Coating 1.67 H.I.
Super Hydrophobic AR
Hydrophobic AR
Hardcoat
Coating 1.74 H.I.
Super Hydrophobic AR
Material Crizal
*
CR39
Poly
Poly Aspheric
Trivex
1.67 High Index
1.74 High Index
Coating Crizal- CR39
Crizal Alize
Crizal Sapphire
Crizal Prevencia
Crizal Transitions Gen-8 Aliza
Crizal Transitions Gen-8 Sapphire
Coating Crizal- Poly
Crizal Alize
Crizal Sapphire
Crizal Prevencia
Crizal Transitions Gen-8 Aliza
Crizal Transitions Gen-8 Sapphire
Coating Crizal- Poly Aspheric
Crizal Alize
Crizal Sapphire
Coating Crizal- Trivex
Crizal Alize
Coating Crizal- 1.67 H.I.
Crizal Alize
Crizal Sapphire
Crizal Transition Gen-8 Sapphire
Coating Crizal- 1.74 H.I.
Crizal Sapphire
Lens Design - Zeiss
*
Zeiss Light D 14
Zeiss Light D 18
Zeiss Smart Life S
Zeiss Smart Life M
Zeiss Smart Life L
Zeiss Digital Lens SV (Add Required)
Zeiss Office Lens Book (3 Feet)
Zeiss Office Lens Desk (7 Feet)
Zeiss Office Lens Room ( 14 Feet)
Lens Design - Bifocal
*
ST28
ST35
Lens Design - Bifocal
*
ST28
ST35
Lens Design - Horizon
*
Horizon View 9
Horizon View 11
Horizon View 13
Horizon Vista Short
Horizon Vista Medium
Horizon Vista Long
Horizon Freestyle
Horizon Millennial +50
Horizon Millennial +75
Horizon Millennial +100
Ar Coating - Zeiss
DuraVision Chrome
DuraVision Silver
DuraVision Platinum
DuraVision Blue Protect
Ar Coating
Horizon Super RES AR
Horizon Ultra RES AR
Horizon Backside Ultra AR
Horizon Backside Super AR
Zeiss Coating - CR39
*
DuraVision Chrome
DuraVision Silver
DuraVision Platinum
DuraVision Blue Protect
PhotoFusion Grey AR
PhotoFusion Grey No-AR
Zeiss Coating - Poly
*
DuraVision Chrome
DuraVision Silver
DuraVision Platinum
DuraVision Blue Protect
PhotoFusion Grey AR
PhotoFusion Grey No-AR
Zeiss Coating - Trivex
*
DuraVision Platinum
DuraVision Blue Protect
Zeiss Coating - 1.67 H.I.
*
DuraVision Platinum
DuraVision Blue Protect
Zeiss Coating - 1.74 H.I.
*
DuraVision Platinum
empty
+1.25
empty
+1.25
Add
*
+0.50
+0.75
+1.00
+1.25
Add
*
+0.50
+0.75
+1.00
Add Ons:
PhotoFusion
No
Photo Gray
Photo Extra Grey
Photo Brown
PhotoFusion
No
Photo Gray
Photo Brown
Transitions-8
No
Trans-8 Gray
Trans-8 Brown
Trans-8 Blue
Trans-8 Green
Transitions-8
No
Trans-8 Gray
Trans-8 Brown
Trans-8 Green
Xtractive Gray
Transition-8/Photochromic
Transitions-8 Gray
Transitions-8 Brown
Transitions-8 Green
Xtractive Gray
Photochromic Gray
Photochromic Brown
Polarized
No
Polarized Gray
Polarized Brown
Polarized Green
Polarized
No
Polarized Gray
Polarized Brown
Polarized G15
Polarized
No
Polarized Gray
Polarized Brown
Polarized Green
Blue Shield Material
Blue Shield
Tint Color
Gray-1
Gray-2
Gray-3
Brown-1
Brown-2
Brown-3
Tint Color
Gray
Brown
Blue
Green
Pink
Yellow
Orange
Purple
Tint %
20%
30%
50%
80%
Flash Mirror
Full Mirror Silver
Full Mirror Gold
Full Mirror Blue
Full Mirror Red
Full Mirror Green
Full Mirror Pink
Full Mirror Purple
Half Mirror Silver
Half Mirror Gold
Half Mirror Blue
Half Mirror Red
Half Mirror Green
Base Curve
1
2
3
4
5
6
7
8
9
R
Sphere
Cyl
Axis
Add
Seg Ht
Right Mono
Far PD
Near PD
L
Sphere
Cyl
Axis
Add
Seg Ht
Left Mono
Far PD
Near PD
Prescribed Prism
Yes
No
R
H Direction
In
Out
Value
V Direction
Up
Down
Value
L
H Direction
In
Out
Value
V Direction
Up
Down
Value
Frame Info:
Frame Supplier
Frame Brand
Frame Model
Frame Measurements:
A (Width)
B (Height)
DBL (Bridge)
ED (Diag)
Notes
