SPEC ORDER FORMPrimary Contact Email (Head of Family/Household) Name of the Patient Optometrist Name Order Summary (Ex. Near Sighted Specs) Order TypeDistanceNearIntermediateBi-focalMulti-focalFrezz ReaderRight Eye/Left Eye Data EntryRight EyeRight Eye SphereRight Eye CylinderRight Eye AxisRight Eye NV AddRight Eye Int AddLeft EyeLeft Eye SphereLeft Eye CylindricalLeft Eye AxisLeft Eye NV AddLeft Eye Int AddOrdering glasses script to send to manufacturer - One of the below:Single Vision DistanceRight Eye Sphere (SVD)Right Eye Cylinder (SVD)Right Eye Axis(SVD)Left Eye Sphere (SVD)Left Eye Cylinder (SVD)Left Eye Axis (SVD)Single Vision NearRight Eye Sphere(SVN)Right Eye Cylindrical(SVN)Right Eye Axis(SVN)Left Eye Sphere (SVN)Left Eye Cylindrical (SVN)Left Eye Axis (SVN)Single Vision IntermediateRight Eye Sphere(SVI)Right Eye Cylindrical(SVI)Right Eye Axis(SVI)Left Eye Sphere(SVI)Left Eye Cylindrical(SVI)Left Eye Axis (SVI)BifocalsRight Eye Sphere(BF)Right Eye Cylindrical(BF)Right Eye Axis (BF)Right Eye NV Add (BF)Left Eye Sphere (BF)Left Eye Cylindrical (BF)Left Eye Axis (BF)Left Eye NV Add (BF)MultifocalsRight Eye Sphere(MF)Right Eye Cylindrical(MF)Right Eye Axis(MF)Right Eye NV Add (MF)Left Eye Sphere (MF)Left Eye Cylindrical(MF)Left Eye Axis (MF)Left Eye NV Add (MF)Frezz readersRight Eye Sphere (FR)Right Eye Cylindrical (FR)Right Eye Axis (FR)Right Eye NV Add (FR)Left Eye Sphere (FR)Left Eye Cylindrical (FR)Left Eye Axis (FR)Left Eye NV Add (FR)Send To...Send Confirmation To.....TimDheeranOtherNotes
