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 ProgressiveNaturales MID PRONaturalens ScleralNaturalens MINIScleral MultifocalVarifocalVarifocal PlusVarifocal Plus High AddTransbylitePediaSITEVIP CONEPrime Limbal GPPrime KonePrime AphakicSOFT KNaturaSOFTNaturaSOFT IC (Irregular Cornea)NaturaSOFT ICR (Irregular Cornea with Reverse Curve)Misc. LensNissel CustomCantor ProstheticContinental SphereContinental ToricContinental BandageMcGuire ConePrime LIMBALPrime LIMBAL SRGPrime KONEPrime SCLERALPrime Mini ScleralAScleralOD MaterialSelect MaterialLab ChoiceBoston B2Boston B4Boston EOBoston EqualensBoston Equalens2Boston ESBoston XOBoston XO2Optimum ClassicOptimum ComfortOptimum ExtraOptimum ExtremeOptimum GP45Optimum Hybrid FSOptimum InfinityInnovision Hydro-2Lagado FlosiLagado Onsi56Lagado PMMALagado SA-18Lagado SA-32Lagado Tyro-97Lifestyle SGP1Lifestyle SGP2Lifestyle SGP3Menicon Z (also available for sclerals)Operm 30Paragon Fluoroperm 151Paragon Fluoroperm 92Paragon Fluoroperm 60Paragon Fluoroperm 30Paragon HDSParagon HDS 100Paragon HDS High Index 1.54Paragon Paraperm EWParagon Paraperm 02Paragon ThinOD MaterialSelect MaterialHefilicon A 45%OD HydrapegPlease Select An OptionYes (Additional fee may Occur)NoOD Material SCLERALSelect MaterialLab ChoiceBoston XOBoston XO2Optimum ExtraOptimum ExtremeOptimum PMMAMenicon ZLagado Tyro-97Paragon HDS 100PMMA ClearOD Material SOFT K*Select MaterialDefinitive Silicone Hydrogel (Quarterly Replacement)Filcon 2 (Yearly Replacement)OD Material NaturaSOFT*Select MaterialDefinitiveOD Material ColorBlueGreenClearOD Soft Material ColorBlueClearOD Lens Parameters Or K's And Rx?*Lens ParametersK's And RxOD Add-On*SphereFront ToricBi-ToricOD Add-On*SphereFront ToricOD Base Curve*OD Base Curve 2*OD Sphere Power*OD Cylinder Power*OD Axis*OD Diameter*OD Iris Size12.5 Std.OD Backing Type*Please Select One(B) Black Back(C) Clear BackOD Pupil Type*Please Select One(C) Closed Pupil(O) Open PupilOD Stock Color*Please Select One0204060709101112131421222324252627282930OD Nissel Stock Color*Please enter color number N01-N102 Example: N43OD Add Power*OD Pupil SizeOD Peripheral Edge5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOD PC OptionSphericalToric PCQuad PCOD Peripheral Edge (90)5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOD Peripheral Edge (180)5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOD Peripheral Edge (270)5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOD AdvancedAdvanced ParametersSimpleOD Optic Zone*OD Scleral Style*StandardALCRCOD Scleral Edge Lift*3X Low2X Low1X LowLowMediumHigh1X High2X High3X High4X High5X High6X HighCUSTOM LIFT (ARC)OD Edge Lift*OD PCZ3 PLUS2 PLUS1 PLUSStandard1 MINUS2 MINUS3 MINUSPara-Central ZoneOD SAG*OD 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 HZ OptionSpherical HZToric HZHaptic Zone (Landing Zone)OD 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 ZoneOD Center Thickness*OD Flat K*OD Steep K*OD Sphere Power*OD Cylinder Power*OD Axis*OD Add PowerIf you would like to upload a picture of the patient's eye, for a Custom Colored Lens, please see the guild lines for how to do so below. Custom Photo Guild File Upload Drop files here or Any additional files that may help upload here for ODOD NotesOS LENSOSNO OS LensOS LensOS Lens Design*Select DesignLab ChoiceStandardNaturalensNaturalens ProgressiveNaturalness MID PRONaturalens ScleralNaturalens MINIScleral MultifocalVarifocalVarifocal PlusVarifocal Plus High AddTransbylitePediaSITEVIP CONEPrime Limbal GPPrime KonePrime AphakicSOFT KNaturaSOFTNaturaSOFT ICNaturaSOFT ICRMisc. LensNissel CustomCantor ProstheticContinental SphereContinental ToricContinental BandageMcGuire ConePrime LIMBALPrime LIMBAL SRGPrime KONEPrime ScleralPrime Mini ScleralScleralOS MaterialSelect MaterialLab ChoiceBoston B2Boston B4Boston EOBoston EqualensBoston Equalens 2Boston ESBoston XOBoston XO2Optimum ClassicOptimum ComfortOptimum ExtraOptimum ExtremeOptimum GP45Optimum Hybrid FSOptimum InfinityInnovision Hydro-2Lagado FlosiLagado Onsi 56Lagado PMMALagado SA-18Lagado SA-32Lagado Tyro-97Lifestyle SGP1Lifestyle SGP2Lifestyle SGP3Menicon ZOperm 30Fluoroperm 151Fluoroperm 92Fluoroperm 60Fluoroperm 30Paragon HDSParagon HDS 100Paragon HDS High Index 1.54Paragon Paraperm EWParagon Paraperm 02Paragon ThinOS MaterialSelect MaterialHefilicon A 45%OS HydrapegYes (Additional Fee may Occur)NoOS Material SCLERALSelect MaterialLab ChoiceBoston XOBoston XO2Optimum ExtraOptimum ExtremeOptimum PMMATyro-97Menicon ZParagon HDS 100OS Material SOFT KSelect MaterialDefinitive Silicone Hydrogel (Quarterly Replacement)Filcon 2 (Yearly Replacement)OS Material NaturaSOFT*Select MaterialDefinitiveOS Material ColorBlueGreenClearOS Soft Material ColorBlueClearOS Lens Parameters Or K's And Rx?*Lens ParametersK's And RxOS Add-On*SphereFront ToricBi-ToricOS Add-On*SphereFront ToricOS Base Curve*OS Base Curve 2*OS Sphere Power*OS Cylinder Power*OS Axis*OS Diameter*OS Iris Size12.5 Std. OS Backing Type*Please Select(B) Black Back(C) Clear BackOS Pupil Type*Please Select One(C) Closed Pupil(O) Open PupilOS Stock Color*Please Select One0204060709101112131421222324252627282930OS Nissel Stock Color*Please enter color number N01-N102 Example: N43OS Scleral Style*StandardALCRCOS Scleral Edge Lift*3X Low2X Low1X LowLowMediumHigh1X High2X High3X High4X High5X High6X HighCUSTOM LIFT (ARC)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 HZ OptionSpherical HZToric HZHaptic Zone (Landing Zone)OS 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 ZoneOS Add PowerOS Pupil SizeOS Peripheral Edge5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOS AdvancedAdvanced ParametersSimpleOS PC OptionSphericalToric PCQuad PCOS Peripheral Edge (90)5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOS Peripheral Edge (180)5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOS Peripheral Edge (270)5 Steps Flat4 Steps Flat3 Steps Flat2 Steps Flat1 Step FlatStandard1 Step Steep2 Steps Steep3 Steps Steep4 Steps Steep5 Steps SteepOS Optic Zone*OS Center Thickness*OS Flat K*OS Steep K*OS Sphere Power*OS Cylinder Power*OS Axis*OS Add Power*If you would like to upload a picture of the patient's eye, for a Custom Colored Lens, please see the guild lines for how to do so below. Custom Photo Guild File Upload Drop files here or Any additional files that may help upload 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 $10.50FedEx 2nd Day $16.00FedEx Overnight $29.00FedEx One Rate To PATIENT $10.50FedEx 2nd Day To Patient $21.00FedEx Overnight To Patient $34.00FedEx InternationalAddress 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 - $25.00Same day RUSH before 12:00 MST This iframe contains the logic required to handle Ajax powered Gravity Forms.
