Dispense Order form
Independent Opticians Dispensing Form
Name
First Name
Last Name
Phone Number
Email
example@example.com
Order Type
SV Near or SV Intermediate:
add the Add onto Sph and leave Add box blank.
Spectacle Lenses
Sph
Cyl
Axis
Prism
Near add
Int Add
Dist PD
Near PD
Heights
R
L
Prism or more than 4 Cyl
lens surcharges
prism R
prism L
R Cyl > 4
L Cyl > 4
Frames
Brand
Yellow sticker
White sticker
Liberty Glasses
Battatura
Jack & Francis
Ray Ban
Prada
Persol
Model
Col Code
Frame Measurements
A
B
DBL
Frame PD
PD
MSU
BVD
Panto
Wrap
measurement
Lenses
Single Vision
*
1.5 UC
1.5 + MAR
1.6
1.67
1.74
Bifocals
*
1.5 Spherical Bif C28
1.61 Spherical Bif C28
Nova Office
*
1.5 NOVA OFFICE
1.6 NOVA OFFICE
1.67 NOVA OFFICE
NOVA PLUS
*
1.5 Nova Plus
1.61 Nova Plus
1.67 Nova Plus
1.74 Aspheric Nova Plus
NOVA TINY
*
1.5 Nova Tiny
1.61 Nova Tiny
1.67 Nova Tiny
1.74 Aspheric Nova Tiny
NOVA UHD
*
1.5 Nova UHD
1.61 Nova UHD
1.67 Nova UHD
1.74 Aspheric Nova UHD
Coating
Blue Protect
Lens Colour
Please Select
Clear
Solid Brown LTF 30
Solid Grey LTF 30
Solid Green LTF 30
Brown Transitions
Grey Transitions
Brown Polarised
Grey Polarised
Green Polarised
Mirror Tint
Prices
Frame Cost
lens base
coating cost
colour cost
RX surcharges
lens total costs
Total Order Cost
Discount Authoriser
Disount Amount
in GBP
Special Instructions
dispensed by
Date
-
Day
-
Month
Year
Date
Submit
Should be Empty: