Practice Name
Account #*
Date
Name of Person Submitting Order*
First
Email for Order Confirmation* Callback Number If we have questions regarding this order
Patient Name*
First
Last
OD Lens OD OD Order Type* Three ways to submit a lens order:
1. Order Specifications – You know exactly which parameters you want. You may order with the “Lens Parameters” or if you wish us to calculate the lens parameters using an empirical algorithm, select “K’s and Rx”. If you need to specify peripherical curves, please use an attachment or enter them in the notes section.
2. Duplicate – Tell us which previous lens order you would like to replicate/copy.
3. Revision – We will decide the changes to the previous order based on your observations. You entrust our consultation team to make the best possible improvements. Please provide detailed information
OD Duplicate Order Reference Which order shall we duplicate (examples: most recent, Inv#, date)
OD Jaime Lens Designs Fractal Lens Second Choice Third Choice
OD Lens Design* Select Design Lab Choice Standard Naturalens Naturalens Progressive Naturalens MID PRO Naturalens CRL Naturalens Scleral Naturalens MINI Scleral PK (reverse geometry) Varifocal Varifocal Plus Varifocal Plus High Add Transbylite PediaSITE VIP CONE SOFT K NaturaSOFT NaturaSOFT IC (Irregular Cornea) NaturaSOFT ICR (Irregular Cornea with Reverse Curve) NaturaSOFT APHAKIC Nicone NRK Nissel Custom TRIAL (1st 2 Free) Nissel Custom Cantor clear TRIAL (1st 2 Free) Cantor Prosthetic Cantor Pinhole Cantor Donut (annular ring) Cantor Occluder Continental SOFT McGuire Cone Soper Cone Rose K Prime LIMBAL Prime LIMBAL SRG Prime KONE Prime SCLERAL Prime Mini Scleral AVT Scleral (1st Gen) Misc. Lens
OD Lens Design (WFD)* Select Design SS PRD SS WFG NaturaSOFT PRD NaturaSOFT WFG
ITERATION OD Warranty OD UPLOAD File Information Please upload all HOA documents for lens
OD Material Select Material Lab Choice Acuity 18 Acuity 58 Acuity 85 Acuity 100 Acuity 200 Boston B2 Boston B4 Boston EO Boston Equalens Boston Equalens2 Boston ES Boston XO Boston XO2 Optimum Classic Optimum Comfort Optimum Extra Optimum Extreme Optimum GP45 Optimum Hybrid FS Optimum Infinite Innovision Hydro-2 Lagado Flosi Lagado Onsi56 Lagado PMMA Lagado SA-18 Lagado SA-32 Lagado Tyro-97 Lifestyle SGP1 Lifestyle SGP2 Lifestyle SGP3 Menicon Z Paragon Fluoroperm 151 Paragon Fluoroperm 92 Paragon Fluoroperm 60 Paragon Fluoroperm 30 Paragon HDS Paragon HDS 100 Paragon HDS High Index 1.54 Paragon Paraperm EW Paragon Paraperm 02 Paragon Thin
OD Material Continental Select Material Hefilicon A 45%
OD Material SCLERAL Select Material Lab Choice Acuity 100 Acuity 200 Boston XO Boston XO2 Optimum Extra Optimum Extreme Optimum Infinite Optimum PMMA Menicon Z Lagado Tyro-97 Paragon HDS 100 PMMA Clear
OD Hydrapeg Please Select An Option Yes (Additional fee may Occur) No
OD Material SOFT K* Select Material Definitive Silicone Hydrogel (Quarterly Replacement) Filcon 2 (Yearly Replacement)
OD Material NaturaSOFT* Select Material Definitive
OD Material Color Orders with the same color OU will have a dot on the right lens unless otherwise specified. All torics have a drill dot for orientation purposes.
OD Material Color SCLERAL OD Soft Material Color OD Lens Parameters Or K's And Rx?* OD Over-Refraction Please note if refraction is over a lens other than the most recent.
OD Dot Location If not a toric lens, leave blank. Clock-hour preferred.
OD Fitting Notes NaFl pattern | Centration | Movement | Comfort | Vision
OD Add-On* If Toric PCs: select Bi-Toric, enter same BC twice and 0 CYL
OD Add-On SOFT* OD SOFT Quantity* 3-packs can only be ordered after a Single
OD Add-On NaturaSOFT IC/ICR* OD Add-On SCLERAL OD Add-On NaturaSOFT OD Base Curve*
OD Base Curve 2*
OD Sphere Power*
Lens Power
OD Sphere Power*
Spectacle Refraction (Not vertexed)
OD Cylinder Power*
Not drum reading
OD Axis*
OD Add Power*
OD Diameter*
OD BOZ
OD CT
OD RZ*
Return Zone
Toric Ex. 525/475
OD LZ*
Landing Zone
Toric Ex. 33/32
OD Iris Size Standard 12.0mm
OD Backing Type* Please Select One (B) Black Back (C) Clear Back
OD Pupil Type* Please Select One (C) Closed Pupil (O) Open Pupil
OD Cantor Stock Color* Please Select One 02 04 06 07 09 10 11 12 13 14 21 22 23 24 25 26 27 28 29 30
OD Nissel Stock Color* Please enter color number N01-N102
Example: N43
OD Pupil Size Prosthetic*
Standard 4.5mm
OD Pinhole size
The aperture or smaller opening size of the pinhole pupil. "Pupil Size Prosthetic" in this case refers to the start of the iris color where the black pupil ends.
OD Pupil Size DOZ*
Default DOZ 3.5mm
OD SEG Height*
Default 1/2 Diameter
OD NaturaSOFT ICR Reverse Curve Radius
OD NaturaSOFT IC/ICR Fit Curve Radius
OD PK#*
Diopters of reverse curve (4 in fitting set)
OD Series Diopters of reverse curve (A=2, B=3, etc.)
A B C D E F G H I J K
OD Series # 1 2 3 4
OD PC Option OD Peripheral Edge 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OD Peripheral Edge (90) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OD Peripheral Edge (90) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OD Peripheral Edge (180) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OD Peripheral Edge (270) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OD Scleral Style* Standard ALC LC RC
OD Scleral Edge Lift* 3X Low 2X Low 1X Low Low Medium High 1X High 2X High 3X High 4X High 5X High 6X High CUSTOM LIFT (ARC)
OD Scleral Toric Edge Lift* (Steeper Meridian)
3X Low 2X Low 1X Low Low Medium High 1X High 2X High 3X High 4X High 5X High 6X High CUSTOM LIFT (ARC)
OD SAG*
OD PCZ Para-Central Zone
3 PLUS 2 PLUS 1 PLUS Standard 1 MINUS 2 MINUS 3 MINUS
OD LZ Limbal Zone
3 PLUS 2 PLUS 1 PLUS Standard 1 MINUS 2 MINUS 3 MINUS
OD HZ Haptic Zone
4 FLAT 3.5 FLAT 3 FLAT 2.5 FLAT 2 FLAT 1.5 FLAT 1 FLAT 0.5 FLAT Standard 0.5 STEEP 1 STEEP 1.5 STEEP 2 STEEP 2.5 STEEP 3 STEEP 3.5 STEEP 4 STEEP
OD THZ Toric Haptic Zone (Steeper Meridian)
4 FLAT 3.5 FLAT 3 FLAT 2.5 FLAT 2 FLAT 1.5 FLAT 1 FLAT 0.5 FLAT Standard 0.5 STEEP 1 STEEP 1.5 STEEP 2 STEEP 2.5 STEEP 3 STEEP 3.5 STEEP 4 STEEP
OD Flat K*
OD Flat K AXIS
ex. (180) degrees
OD Steep K*
OD Steep K AXIS
ex. (090) degrees
OD HVID
Horizontal Visual Iris Diameter
OD BFS
Best Fit Sphere
If you would like to upload a picture of the patient's eye for a custom image match, please see the guideline below:
Nissel Custom Image Guide
OD Corneal Condition / Clinical Application
OD File Upload Any additional helpful files may be uploaded here for OD
OD Notes
OS LENS OS OS Order Type* Three ways to submit a lens order: 1. Order Specifications – You know exactly which parameters you want. You may order with the “Lens Parameters” or if you wish us to calculate the lens parameters using an empirical algorithm, select “K’s and Rx”. If you need to specify peripherical curves, please use an attachment or enter them in the notes section. 2. Duplicate – Tell us which previous lens order you would like to replicate/copy. 3. Revision – We will decide the changes to the previous order based on your observations. You entrust our consultation team to make the best possible improvements. Please provide detailed information
OS Duplicate Order Reference Which order shall we duplicate (examples: most recent, Inv#, date)
OS Lens Design* Select Design Lab Choice Standard Naturalens Naturalens Progressive Naturalens MID PRO Naturalens CRL Naturalens Scleral Naturalens MINI Scleral PK (reverse geometry) Varifocal Varifocal Plus Varifocal Plus High Add Transbylite PediaSITE VIP CONE SOFT K NaturaSOFT NaturaSOFT IC NaturaSOFT ICR NaturaSOFT APHAKIC Nicone NRK Nissel Custom TRIAL (1st 2 Free) Nissel Custom Cantor clear TRIAL (1st 2 Free) Cantor Prosthetic Cantor Pinhole Cantor Donut (annular ring) Cantor Occluder Continental SOFT McGuire Cone Soper Cone Rose K Prime LIMBAL Prime LIMBAL SRG Prime KONE Prime Scleral Prime Mini Scleral AVT Scleral (1st Gen) Misc. Lens
OS Lens Design (WFD)* Select Design SS PRD SS WFG NaturaSOFT PRD NaturaSOFT WFG
OS Warranty OS UPLOAD File Information Please upload all HOA documents for lens
OS Material Select Material Lab Choice Acuity 18 Acuity 58 Acuity 85 Acuity 100 Acuity 200 Boston B2 Boston B4 Boston EO Boston Equalens Boston Equalens 2 Boston ES Boston XO Boston XO2 Optimum Classic Optimum Comfort Optimum Extra Optimum Extreme Optimum GP45 Optimum Hybrid FS Optimum Infinite Innovision Hydro-2 Lagado Flosi Lagado Onsi 56 Lagado PMMA Lagado SA-18 Lagado SA-32 Lagado Tyro-97 Lifestyle SGP1 Lifestyle SGP2 Lifestyle SGP3 Menicon Z Fluoroperm 151 Fluoroperm 92 Fluoroperm 60 Fluoroperm 30 Paragon HDS Paragon HDS 100 Paragon HDS High Index 1.54 Paragon Paraperm EW Paragon Paraperm 02 Paragon Thin
OS Material Continental Select Material Hefilicon A 45%
OS Material SCLERAL Select Material Lab Choice Acuity 100 Acuity 200 Boston XO Boston XO2 Optimum Extra Optimum Extreme Optimum Infinite Optimum PMMA Tyro-97 Menicon Z Paragon HDS 100
OS Hydrapeg Yes (Additional Fee may Occur) No
OS Material SOFT K Select Material Definitive Silicone Hydrogel (Quarterly Replacement) Filcon 2 (Yearly Replacement)
OS Material NaturaSOFT Select Material Definitive
OS Material Color Orders with the same color OU will have a dot on the right lens unless otherwise specified. All torics have a drill dot for orientation purposes.
OS Material Color SCLERAL OS Soft Material Color OS Lens Parameters Or K's And Rx?* OS Over-Refraction Please note if refraction is over a lens other than the most recent.
OS Dots Location If not a toric lens, leave blank. Clock-hour preferred.
OS Fitting Notes NaFl pattern | Centration | Movement | Comfort | Vision
OS Add-On* If Toric PCs: select Bi-Toric, enter same BC twice and 0 CYL
OS Add-On SCLERAL OS Add-On SOFT* OS SOFT Quantity* 3-packs can only be ordered after a Single
OS Add-On NaturaSOFT OS Add-On NaturaSOFT IC/ICR* OS Base Curve*
OS Base Curve 2*
OS Sphere Power*
Lens Power
OS Sphere Power*
Spectacle Refraction (Not vertexed)
OS Cylinder Power*
Not drum reading
OS Axis*
OS Add Power*
OS Diameter*
OS BOZ
OS CT
OS RZ*
Return Zone
Toric Ex. 525/475
OS LZ*
Landing Zone
Toric Ex. 33/32
OS Iris Size Standard 12.0mm
OS Backing Type* Please Select (B) Black Back (C) Clear Back
OS Pupil Type* Please Select One (C) Closed Pupil (O) Open Pupil
OS Cantor Stock Color* Please Select One 02 04 06 07 09 10 11 12 13 14 21 22 23 24 25 26 27 28 29 30
OS Nissel Stock Color* Please enter color number N01-N102
Example: N43
OS Scleral Style* Standard ALC LC RC
OS Scleral Edge Lift* 3X Low 2X Low 1X Low Low Medium High 1X High 2X High 3X High 4X High 5X High 6X High CUSTOM LIFT (ARC)
OS Scleral Toric Edge Lift* (Steeper Meridian)
3X Low 2X Low 1X Low Low Medium High 1X High 2X High 3X High 4X High 5X High 6X High CUSTOM LIFT (ARC)
OS SAG*
OS PCZ Para-Central Zone
3 PLUS 2 PLUS 1 PLUS Standard 1 MINUS 2 MINUS 3 MINUS
OS LZ Limbal Zone
3 PLUS 2 PLUS 1 PLUS Standard 1 MINUS 2 MINUS 3 MINUS
OS HZ Haptic Zone
4 FLAT 3.5 FLAT 3 FLAT 2.5 FLAT 2 FLAT 1.5 FLAT 1 FLAT 0.5 FLAT Standard 0.5 STEEP 1 STEEP 1.5 STEEP 2 STEEP 2.5 STEEP 3 STEEP 3.5 STEEP 4 STEEP
OS THZ Toric Haptic Zone (Steeper Meridian)
4 FLAT 3.5 FLAT 3 FLAT 2.5 FLAT 2 FLAT 1.5 FLAT 1 FLAT 0.5 FLAT Standard 0.5 STEEP 1 STEEP 1.5 STEEP 2 STEEP 2.5 STEEP 3 STEEP 3.5 STEEP 4 STEEP
OS Pupil Size DOZ*
Default DOZ 3.5mm
OS SEG Height
Default 1/2 Diameter
OS Pupil Size Prosthetic*
Standard 4.5mm
OS Pinhole size
The aperture or smaller opening size of the pinhole pupil. "Pupil Size Prosthetic" in this case refers to the start of the iris color where the black pupil ends.
OS NaturaSOFT ICR Reverse Curve Radius
OS NaturaSOFT IC/ICR Fit Curve Radius
OS PK#*
Diopters of reverse curve (4 in fitting set)
OS Series Diopters of reverse curve (A=2, B=3, etc.)
A B C D E F G H I J K
OS Series # 1 2 3 4
OS PC Option OS Peripheral Edge 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OS Peripheral Edge (90) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OS Peripheral Edge (90) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OS Peripheral Edge (180) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OS Peripheral Edge (270) 5 Flat 4 Flat 3 Flat 2 Flat 1 Flat Standard 1 Steep 2 Steep 3 Steep 4 Steep 5 Steep
OS Flat K*
OS Flat Axis
ex. (180) degrees
OS Steep K*
OS Steep Axis
ex. (090) degrees
OS HVID
Horizontal Visual Iris Diameter
OS BFS
Best Fit Sphere
If you would like to upload a picture of the patient's eye for a custom image match, please see the guideline below:
Nissel Custom Image Guide
OS Corneal Condition / Clinical Application
OS File Upload
Any additional helpful files may be uploaded here for OS
OS Notes
Acknowledgement* By checking the box below, you acknowledge this product is Non-Warranted and Non-Returnable.
Shipping Shipping Method* Choose Shipping Pickup At Lab Local Crystal Courier FedEx One Rate 2-Day $11.50 FedEx Overnight $32.00 FedEx One Rate 2-Day To PATIENT $11.50 FedEx Overnight To PATIENT $36.00 FedEx International USPS Priority $10.00 USPS Priority to PATIENT $10.00 (for P.O. Boxes) USPS Express $28.00 USPS Express to PATIENT $28.00 (for P.O. Boxes) 3rd Party Ground 3rd Party Overnight 3rd Party Ground to PATIENT 3rd Party Overnight to PATIENT
Address
Need It Rushed? Please submit orders before 10:30 MT same-day RUSH, otherwise, the order will finish the next day. PediaSITE RUSH is complimentary. Does not include shipping charge.
Shipping / Order Notes
Cancellation in Process Policy* Orders that are cancelled during the manufacturing process and prior to shipping will be charged a materials and processing fee. Corneal lenses will be charged $15 per lens and scleral lenses will be charged $30 per lens.
