š”
How to use:
Fill in patient prescription details, check the lens options needed, then click
Submit Order
. Fields marked
*
are required. Hover over the
i
icons for help on each field.
Hide
š§ Submit Order
šØ Print / Save as PDF
Clear
ENCORE
OPTICAL SUPPLY
4519 162nd Street, Flushing, NY 11358
P: 718-888-1490 FAX: 718-888-7739
Order website:
www.order-encore.com
Account
Name:
*
Acct #:
*
Patient:
*
Date:
/
/
SPHERE
*
i
CYLINDER
i
AXIS
i
ADD
i
SEG. HGT.
i
O.C HGT.
i
R
L
PD
*
TINTS
Solid
Gradient
G15
Grey
Brown
Color
%
PRISM
i
BASE CURVE
i
DISTANCE
i
NEAR
i
R
L
EYE SIZE
i
DBL
i
B BOX
i
E.D.
i
PHOTOCHROMIC SPIN
i
Grey
Brown
G15
LENSE STYLE
*
i
CORRIDOR
i
MATERIAL
*
i
SV
FT28
FREE FORM PAL
Optotech / MD
Optotech / 4k AllView
IOT / Endless
17 mm
14 mm
CR39
1.60
Poly
1.67
Trivex
1.74
AR/SRC COATING
i
POLARIZED COLOR
i
SRC
HMC
Back Side AR
Super Hydrophobic
Blue Cut Blue AR
Grey
Brown
G15
3 BC
4 BC
5 BC
6 BC
FRAME
*
i
Zyl
Metal
Drill
Groove
Knife Edge
SPECIAL INSTRUCTION
i