New Order

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DOCTOR DASHBOARD

Order Type

Patient Name

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Account Number

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One/two Eyes

Eye

Trial Lens Used:

Lens Design

Diameter

SAG

Base Curve

Lens Power

Material

Color

Add-Ons

Modifications Requested

Trial Lens Used (right):

Lens Design (right)

Diameter (right)

SAG (right)

Base Curve (right)

Lens Power (right)

Material (right)

Color (right)

Add-Ons (right)

Modifications Requested (left)

Fitting information AT INSERTION (right):

Central Clearance (right)

Limbal Clearance (right)

Scleral Alignment (right)

Rotation (right)

ORX (right)

Please notate if applicable (right)

Impingement (right)

Edge Stand-Off (right)

Pinguecula (right)

Limbal Curve indicator (temporal) (right)

Observations / Modifications (right)

Notes (right)

Trial Lens Used (left):

Lens Design (left)

Diameter (left)

SAG (left)

Base Curve (left)

Lens Power (left)

Material (left)

Color (left)

Add-Ons (left)

Modifications Requested (right)

Fitting information AT INSERTION (left):

Central Clearance (left)

Limbal Clearance (left)

Scleral Alignment (left)

Rotation (left)

ORX (left)

Please notate if applicable (left)

Impingement (left)

Edge Stand-Off (left)

Pinguecula (left)

Limbal Curve indicator (temporal) (left)

Observations / Modifications (left)

Notes (left)

Fitting information AT INSERTION:

Central Clearance

Limbal Clearance

Scleral Alignment

Rotation

ORX

Please notate if applicable

Impingement

Edge Stand-Off

Pinguecula

Limbal Curve indicator (temporal)

Observations / Modifications

Notes

Attach Files

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DOCTOR DASHBOARD

NEW ORDER

Trial Lens Used:

Trial Lens Used (right):

Fitting information AT INSERTION (right):

Please notate if applicable (right)

Trial Lens Used (left):

Fitting information AT INSERTION (left):

Please notate if applicable (left)

Fitting information AT INSERTION:

Please notate if applicable

Attach Files

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Contact lenses

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Learning Center

White Papers / Resources

Who We Are

DOCTOR DASHBOARD

NEW ORDER

Trial Lens Used:

Trial Lens Used (right):

Fitting information AT INSERTION (right):

Please notate if applicable (right)

Trial Lens Used (left):

Fitting information AT INSERTION (left):

Please notate if applicable (left)

Fitting information AT INSERTION:

Please notate if applicable

Attach Files

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New Order options:

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