Bluegrass Eyewear Order Form

Bluegrass Eyewear Order Form

Please refer to the current price sheet for product availability or contact Customer Service at info@bluegrasseyewear.com or 770-847-8788 if you have any questions.
Order Date

MonthDayYear
Practice Name
Account #
Practice Email
example@example.com
Patient Name
Patient Name
Order Type
Lens(es) Supplied by Customer?
Is This a Remake?
Remake Reason
Brief description of issue requiring remake
Lens Information
Lens Type
Lined Multifocal Type
Progressive Type
Occupational Progressive Design
Value Progressive Design
Standard Progressive Design
Digital/Custom Progressive Design
Lens Treatment
Lens Treatments
Type of Blue Block
Type of Photochromic
Polar Color
Lens Material
Lens Materials
Coating
Coatings
AR Coating
Tint/Mirror/UV
Tint Color
Tint %
Mirror Color
Prescription Information
OD Sph
OD Cyl
OD Axis
OD Add
OD Seg Ht
OD Dist. PD
OD Near PD
OD Prism (In/Out, Up/Down)
OD OC Ht
OS Sph
OS Cyl
OS Axis
OS Add
OS Seg Ht
OS Dist. PD
OS Near PD
OS Prism (In/Out, Up/Down)
OS OC Ht
Frame Information
Frame
Edge Type
Edge Treatments
Repair Work
Frame Vendor
Model Name
Color
Frame Material
A
B
ED
DBL
Special Instructions
Frame Receiving

Other
Order Fulfillment

Other
Please review your order and make sure all of the information is correct before clicking Submit.

An Order Confirmation will be sent to the email address entered under Practice Email. If you have any questions, please contact Customer Service at info@bluegrasseyewear.com or 770-847-8788.

Thank you!
Should be Empty:

Lens Information