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*

PairOD OnlyOS Only
Lens(es) Supplied by Customer?*

YesNo
Is This a Remake?*

YesNo
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

Gradient TintSolid TintMirror CoatingTint + Mirror CoatingUVScratch Coating
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*

To ComeEnclosedNo Frame: UncutNo Frame: Stock Lens
Edge Type

Hide a BevelGrooved RimlessDrill MountSport Edge/Wrap Frame
Edge Treatments

Satin Edge Polish (Standard)Roll & PolishHigh Luster PolishNo Polish Edge
Repair Work

Manual Edging/Repair for Hide-A-BevelManual Edging/Repair for Grooved RimlessManual Edging/Repair for Drill MountsManual Edging/Repair for Sport Edge/Wrap FrameOther Repairs
Frame Vendor
Model Name
Color
Frame Material
A
B
ED
DBL
Special Instructions
Frame Receiving*

ECP Drop-Off at Bluegrass Eyewear (1525 Bluegrass Lakes Pkwy, Alpharetta, GA 30004)Send Shipping LabelOther
Order Fulfillment*

ECP Pick-Up at Bluegrass Eyewear (1525 Bluegrass Lakes Pkwy, Alpharetta, GA 30004)Ship via Carrier to Account Address on FileOther
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!
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Bluegrass Eyewear Order Form

Lens Information

Prescription Information

Frame Information