Contact Lens Orders Contact lens Order Placement Practice NameAccount #*Date Name of Person Submitting Order* First Email for Order Confirmation* Enter Email Confirm Email Patient Name* First Last OD LensODNO OD LensOD LensOD Jaime Lens DesignsFractal LensSecond ChoiceThird ChoiceOD Lens Design*Select DesignLab ChoiceStandardNaturalensNaturalens ProgressiveNaturalens MID PRONaturalens CRLNaturalens ScleralNaturalens MINI ScleralPK (reverse geometry)VarifocalVarifocal PlusVarifocal Plus High AddTransbylitePediaSITEVIP CONESOFT KNaturaSOFTNaturaSOFT IC (Irregular Cornea)NaturaSOFT ICR (Irregular Cornea with Reverse Curve)Misc. LensNissel CustomCantor ProstheticCantor PinholeCantor Donut (annular ring)Cantor OccluderContinental SOFTMcGuire ConeSoper ConeRose KPrime LIMBALPrime LIMBAL SRGPrime KONEPrime SCLERALPrime Mini ScleralAVT Scleral (1st Gen)OD Lens Design (WFD)*Select DesignNaturaSOFT HOA TRIALNaturaSOFT HOA RxOD WarrantyOD Warranted (90 days for refits)OD Non-WarrantedHOA File Information Drop files here or Accepted file types: jpg, gif, png, pdf, v5f, sod, s0d. Please upload all HOA documents for lensOD MaterialSelect MaterialLab ChoiceAcuity 18Acuity 58Acuity 85Acuity 100Acuity 200Boston B2Boston B4Boston EOBoston EqualensBoston Equalens2Boston ESBoston XOBoston XO2Optimum ClassicOptimum ComfortOptimum ExtraOptimum ExtremeOptimum GP45Optimum Hybrid FSOptimum InfiniteInnovision Hydro-2Lagado FlosiLagado Onsi56Lagado PMMALagado SA-18Lagado SA-32Lagado Tyro-97Lifestyle SGP1Lifestyle SGP2Lifestyle SGP3Menicon ZParagon Fluoroperm 151Paragon Fluoroperm 92Paragon Fluoroperm 60Paragon Fluoroperm 30Paragon HDSParagon HDS 100Paragon HDS High Index 1.54Paragon Paraperm EWParagon Paraperm 02Paragon ThinOD Material ContinentalSelect MaterialHefilicon A 45%OD Material SCLERALSelect MaterialLab ChoiceAcuity 100Acuity 200Boston XOBoston XO2Optimum ExtraOptimum ExtremeOptimum InfiniteOptimum PMMAMenicon ZLagado Tyro-97Paragon HDS 100PMMA ClearOD HydrapegPlease Select An OptionYes (Additional fee may Occur)NoOD Material SOFT K*Select MaterialDefinitive Silicone Hydrogel (Quarterly Replacement)Filcon 2 (Yearly Replacement)OD Material NaturaSOFT*Select MaterialDefinitiveOD Material ColorBlueGreenClearOrders with the same color OU will have a dot on the right lens unless otherwise specified. All torics have a drill dot for orientation purposes. OD Material Color SCLERALBlueClearOD Soft Material ColorVisi TintClearOD Lens Parameters Or K's And Rx?*Lens ParametersK's And RxOD Add-On*SphereFront ToricBi-ToricOD Add-On SOFT*SphereToricOD SOFT Quantity*Single (Warranted)3-pack (Non-Warranted)4-pack (Non-Warranted)3-packs can only be ordered after a SingleOD Add-On NaturaSOFT IC/ICR*SphereToricMultifocalOD Add-On SCLERAL Front-Toric Multifocal Toric HZ (Haptic Zone) OD Add-On NaturaSOFT Toric Multifocal OD Base Curve*OD Base Curve 2*OD Sphere Power*Lens PowerOD Sphere Power*Spectacle Refraction (Not vertexed)OD Cylinder Power*OD Axis*OD Add Power*OD Diameter*OD RZ*Return Zone Toric Ex. 525/475OD LZ*Landing Zone Toric Ex. 33/32OD Iris SizeStandard 12.0mmOD Backing Type*Please Select One(B) Black Back(C) Clear BackOD Pupil Type*Please Select One(C) Closed Pupil(O) Open PupilOD Cantor Stock Color*Please Select One0204060709101112131421222324252627282930OD Nissel Stock Color*Please enter color number N01-N102 Example: N43OD Pupil Size Prosthetic*Standard 4.5mmOD Pinhole sizeThe aperture or smaller opening size of the pinhole pupil. "Pupil Size Prosthetic" in this case refers to the start of the iris color where the black pupil ends. OD Pupil Size DOZ*Default DOZ 3.5mmOD SEG Height*Default 1/2 DiameterOD NaturaSOFT ICR Reverse Curve RadiusOD NaturaSOFT IC/ICR Fit Curve RadiusOD PK#*Diopters of reverse curve (4 in fitting set)OD SeriesABCDEFGHIJKDiopters of reverse curve (A=2, B=3, etc.)OD PC OptionSphericalToric PCQuad PCOD Peripheral Edge5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOD Peripheral Edge (90)5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOD Peripheral Edge (180)5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOD Peripheral Edge (270)5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOD Scleral Style*StandardALCLCRCOD Scleral Edge Lift*3X Low2X Low1X LowLowMediumHigh1X High2X High3X High4X High5X High6X HighCUSTOM LIFT (ARC)OD Scleral Toric Edge Lift*3X Low2X Low1X LowLowMediumHigh1X High2X High3X High4X High5X High6X HighCUSTOM LIFT (ARC)(Steeper Meridian)OD SAG*OD PCZ3 PLUS2 PLUS1 PLUSStandard1 MINUS2 MINUS3 MINUSPara-Central ZoneOD LZ3 PLUS2 PLUS1 PLUSStandard1 MINUS2 MINUS3 MINUSLimbal ZoneOD HZ4 FLAT3.5 FLAT3 FLAT2.5 FLAT2 FLAT1.5 FLAT1 FLAT0.5 FLATStandard0.5 STEEP1 STEEP1.5 STEEP2 STEEP2.5 STEEP3 STEEP3.5 STEEP4 STEEPHaptic ZoneOD THZ4 FLAT3.5 FLAT3 FLAT2.5 FLAT2 FLAT1.5 FLAT1 FLAT0.5 FLATStandard0.5 STEEP1 STEEP1.5 STEEP2 STEEP2.5 STEEP3 STEEP3.5 STEEP4 STEEPToric Haptic Zone (Steeper Meridian)OD Flat K*OD Flat K AXISex. (180) degreesOD Steep K*OD Steep K AXISex. (090) degreesOD HVIDHorizontal Visual Iris DiameterOD BFSBest Fit SphereIf you would like to upload a picture of the patient's eye for a custom image match, please see the guideline below: Nissel Custom Image Guide File Upload Drop files here or Any additional helpful files may be uploaded here for ODOD NotesOS LENSOSNO OS LensOS LensOS Lens Design*Select DesignLab ChoiceStandardNaturalensNaturalens ProgressiveNaturalens MID PRONaturalens CRLNaturalens ScleralNaturalens MINI ScleralPK (reverse geometry)VarifocalVarifocal PlusVarifocal Plus High AddTransbylitePediaSITEVIP CONESOFT KNaturaSOFTNaturaSOFT ICNaturaSOFT ICRMisc. LensNissel CustomCantor ProstheticCantor PinholeCantor Donut (annular ring)Cantor OccluderContinental SOFTMcGuire ConeSoper ConeRose KPrime LIMBALPrime LIMBAL SRGPrime KONEPrime ScleralPrime Mini ScleralAVT Scleral (1st Gen)OS Lens Design (WFD)*Select DesignNaturaSOFT HOA TRIALNaturaSOFT HOA RxOS WarrantyOS Warranted (90 days for refits)OS Non-WarrantedOS HOA File Information Drop files here or Accepted file types: jpg, gif, png, pdf, v5f, sod, s0d. Please upload all HOA documents for lens OS MaterialSelect MaterialLab ChoiceAcuity 18Acuity 58Acuity 85Acuity 100Acuity 200Boston B2Boston B4Boston EOBoston EqualensBoston Equalens 2Boston ESBoston XOBoston XO2Optimum ClassicOptimum ComfortOptimum ExtraOptimum ExtremeOptimum GP45Optimum Hybrid FSOptimum InfiniteInnovision Hydro-2Lagado FlosiLagado Onsi 56Lagado PMMALagado SA-18Lagado SA-32Lagado Tyro-97Lifestyle SGP1Lifestyle SGP2Lifestyle SGP3Menicon ZFluoroperm 151Fluoroperm 92Fluoroperm 60Fluoroperm 30Paragon HDSParagon HDS 100Paragon HDS High Index 1.54Paragon Paraperm EWParagon Paraperm 02Paragon ThinOS Material ContinentalSelect MaterialHefilicon A 45%OS Material SCLERALSelect MaterialLab ChoiceAcuity 100Acuity 200Boston XOBoston XO2Optimum ExtraOptimum ExtremeOptimum InfiniteOptimum PMMATyro-97Menicon ZParagon HDS 100OS HydrapegYes (Additional Fee may Occur)NoOS Material SOFT KSelect MaterialDefinitive Silicone Hydrogel (Quarterly Replacement)Filcon 2 (Yearly Replacement)OS Material NaturaSOFT*Select MaterialDefinitiveOS Material ColorBlueGreenClearOrders with the same color OU will have a dot on the right lens unless otherwise specified. All torics have a drill dot for orientation purposes. OS Material Color SCLERALBlueClearOS Soft Material ColorVisi TintClearOS Lens Parameters Or K's And Rx?*Lens ParametersK's And RxOS Add-On*SphereFront ToricBi-ToricOS Add-On SCLERAL Front-Toric Multifocal Toric HZ (Haptic Zone) OS Add-On SOFT*SphereToricOS SOFT Quantity*Single (Warranted)3-pack (Non-Warranted)4-pack (Non-Warranted)3-packs can only be ordered after a SingleOS Add-On NaturaSOFT Toric Multifocal OS Add-On NaturaSOFT IC/ICR*SphereToricMultifocalOS Base Curve*OS Base Curve 2*OS Sphere Power*Lens PowerOS Sphere Power*Spectacle Refraction (Not vertexed)OS Cylinder Power*OS Axis*OS Add Power*OS Diameter*OS RZ*Return Zone Toric Ex. 525/475OS LZ*Landing Zone Toric Ex. 33/32OS Iris SizeStandard 12.0mmOS Backing Type*Please Select(B) Black Back(C) Clear BackOS Pupil Type*Please Select One(C) Closed Pupil(O) Open PupilOS Cantor Stock Color*Please Select One0204060709101112131421222324252627282930OS Nissel Stock Color*Please enter color number N01-N102 Example: N43OS Scleral Style*StandardALCLCRCOS Scleral Edge Lift*3X Low2X Low1X LowLowMediumHigh1X High2X High3X High4X High5X High6X HighCUSTOM LIFT (ARC)OS Scleral Toric Edge Lift*3X Low2X Low1X LowLowMediumHigh1X High2X High3X High4X High5X High6X HighCUSTOM LIFT (ARC)(Steeper Meridian)OS SAG*OS PCZ3 PLUS2 PLUS1 PLUSStandard1 MINUS2 MINUS3 MINUSPara-Central ZoneOS LZ3 PLUS2 PLUS1 PLUSStandard1 MINUS2 MINUS3 MINUSLimbal ZoneOS HZ4 FLAT3.5 FLAT3 FLAT2.5 FLAT2 FLAT1.5 FLAT1 FLAT0.5 FLATStandard0.5 STEEP1 STEEP1.5 STEEP2 STEEP2.5 STEEP3 STEEP3.5 STEEP4 STEEPHaptic ZoneOS THZ4 FLAT3.5 FLAT3 FLAT2.5 FLAT2 FLAT1.5 FLAT1 FLAT0.5 FLATStandard0.5 STEEP1 STEEP1.5 STEEP2 STEEP2.5 STEEP3 STEEP3.5 STEEP4 STEEPToric Haptic Zone (Steeper Meridian)OS Pupil Size DOZ*Default DOZ 3.5mmOS SEG HeightDefault 1/2 DiameterOS Pupil Size Prosthetic*Standard 4.5mmOS Pinhole sizeThe aperture or smaller opening size of the pinhole pupil. "Pupil Size Prosthetic" in this case refers to the start of the iris color where the black pupil ends. OS NaturaSOFT ICR Reverse Curve RadiusOS NaturaSOFT IC/ICR Fit Curve RadiusOS PK#*Diopters of reverse curve (4 in fitting set)OS SeriesABCDEFGHIJKDiopters of reverse curve (A=2, B=3, etc.)OS PC OptionSphericalToric PCQuad PCOS Peripheral Edge5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOS Peripheral Edge (90)5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOS Peripheral Edge (180)5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOS Peripheral Edge (270)5 Flat4 Flat3 Flat2 Flat1 FlatStandard1 Steep2 Steep3 Steep4 Steep5 SteepOS Flat K*OS Flat Axisex. (180) degreesOS Steep K*OS Steep Axisex. (090) degreesOS HVIDHorizontal Visual Iris DiameterOS BFSBest Fit SphereIf you would like to upload a picture of the patient's eye for a custom image match, please see the guideline below: Nissel Custom Image Guide File Upload for Order Drop files here or Any additional helpful files may be uploaded here for OSOS NotesAcknowledgement*By checking the below box you acknowledge this lens is Non-Warranted and Non-Returnable. I Agree to the Terms and Conditions Shipping*Choose ShippingLocal Crystal CourierFedEx One Rate 2-Day $10.50FedEx Overnight $29.00FedEx One Rate 2-Day To PATIENT $10.50FedEx Overnight To PATIENT $34.00FedEx InternationalUSPS Priority $10.00USPS Priority to PATIENT $10.00 (Only for P.O. Boxes)Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Need It Rushed?RUSH - $25.00* Does not include SHIPPING. Cut-off times for same-day RUSH: - Uncoated lenses before 12:00 MT - Hydra-PEG orders before 11:00 MT - PediaSITE RUSH is complimentary Shipping / Order Notes This iframe contains the logic required to handle Ajax powered Gravity Forms.
