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Account Number
Order Type
Patient Name
Eye
One/two Eyes

Trial Lens Used

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Lens Design
Diameter
SAG
Base Curve
Best Trial Lens Used
Over-refraction
Material
Color
Add-Ons
Modifications Requested

Fitting information AT INSERTION

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Central Clearance
Limbal Clearance
Scleral Alignment
Rotation
ORX

Please notate if applicable

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Impingement
Edge Stand-Off
Pinguecula
Limbal Curve indicator (temporal)
Observations / Modifications
Notes

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