Contact Lens Request Form
Please fill in the following form to enable us to add in the Contact Lens you are requesting.Should you require some help, please do not hesitate to contact us on support@optinetuk.com or 0800 310 2400.
Your Name
*
Name of contact
Your Practice
*
Name of the practice requesting
Phone Number
*
-
Area Code
Phone Number
Email
*
We can email you an update to the changes
Supplier
*
Please Select
Alcon (includes: Ciba Vision)
Ascend
Bausch & Lomb
Belgravia Contact Lenses (Bespoke Hospital Lenses
Cantor & Nissel
ClearLab
CooperVision
CooperVision mediflex (NEG only)
David Thomas
Daysoft - Provis
EyeTech
Harmony
i-GO Optical Ltd
Jack Allen
Johnson & Johnson
Mark Ennovy
Menicon
No 7
Northern Lenses
OK Lens
Optosoft
Safilens
Sauflon (part of CooperVision)
Scotlens
SynergEyes
Thompson Contact Lenses
Ultravision
Veni Vidi
Visionary Optics
Visioneering Technologies (VTI)
X-CEL by Hydrogel Vision
New Supplier - Please use the notes box at the bottom of the form
Description (Name of lens)
*
Type
*
Please Select
GP
Hard
Hybrid
Soft
Design
*
Please Select
Multifocal
Multifocal Toric
Special
Spherical
Toric
Wearing Plan
*
Please Select
Daily Wear (Daily use ONLY)
Daily Wear or Extended Wear (can either be used daily or overnight)
Extended Wear (can be left in overnight)
Replacement Schedule
*
Please Select
Daily
Every 7 Days
Every 2 Weeks
Monthly
12 Monthly
3 or 6 Monthly
3 Monthly
6 Monthly
Base Curve
*
Separate multiple base curves with a comma
Diameter
*
Separate multiple diameters with a comma
Powers
Cyls
*
Separate cyls with a comma
Axis
Adds
Pack Size
Separate pack size with a comma
Please provide any information here that you feel is relevant
You may enter the link to the lens on the supplier's website
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