Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Sales Associate Name
*
First Name
Last Name
Customer's Name
*
First Name
Last Name
Customer’s Email Address
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
SEX
Please Select
Female
Male
—
SPH
CYL
AXIS
OD
OS
AD
PD
SEG/FH
Right
Left
Lens Type
Please Select
Singe Vision
Kryptok
Progressive
Flat Top
Lens Option
Please Select
Uncoated
MultiCoated
Progressive
Transition
MF Type
Len Add On
Special Instructions
Doctors Signature
*
Order Form
Description
Price
Frame with lens
Lens Only
Mounting
Tinting
Other
Other
Other
Total
Down Payment
Balance*
Pick Up Date
*
-
Month
-
Day
Year
Date
Orders not claimed after 7 days of pick up date will be forfeited and balance is not refundable.
Customers Signature
*
Submit
Should be Empty: