MIC OPTICAL Ordering Form

DATE:*
MonthDayYear
1
MIC OPTICAL 丹佛华埠眼镜公司
2200 W Alameda Ave. #16 Denver, CO 80223 Tel: 720-572-7999
CONTACT INFORMATION
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Phone:
Email Address:
Appointment
Reason for the appt.
Distance:
Sphere Cylinder Axis Prism Add Base Decenter
OD (R)
OS (L)
Secondary use:
Sphere Cylinder Axis Prism Add Base Decenter
OD (R)
OS (L)
Contact Lenses:
Sphere Cylinder Axis BC DIA
OD (R)
OS (L)
Contact Lenses Type
Adddition
Seg. HT. Inset. Total. PD.
OD
OS
A. B ED DBL
Frame Size
Lenses Diameter
Frame Info
Product
Lenses Type
Single Vision Lenses
CR-39 (+3.00 to -4.00, Up to -2.00 CYL) $69Polycarbonate (+3.00 to -5.00, up to -2.00 CYL) $801.60 High Index (Up to -6.00, up to -2.00 CYL) $1201.67 Extra High Index (-2.00 to -15.00, up to -2.00 CYL) $149
SV Lenses Qty
Progressive Lenses
CR-39 (+3.00 to -4.00, Up to -2.00 CYL) $140Polycarbonate (+3.00 to -5.00, up to -2.00 CYL) $1501.60 High Index (Up to -6.00, up to -2.00 CYL) $1601.67 Extra High Index (-2.00 to -15.00, up to -2.00 CYL) $250
Progressive Lenses Qty
Transitions Lenses
SV CR-39 (+3.00 to -4.00, Up to -2.00 CYL) $120SV Polycarbonate (+3.00 to -5.00, up to -2.00 CYL) $160SV 1.60 High Index (Up to -6.00, up to -2.00 CYL) $180SV 1.67 Extra High Index (-2.00 to -15.00, up to -2.00 CYL) $190PAL CR-39 (+3.00 to -4.00, Up to -2.00 CYL) $205PAL Polycarbonate (+3.00 to -5.00, up to -2.00 CYL) $225PAL 1.60 High Index (Up to -6.00, up to -2.00 CYL) $235PAL 1.67 Extra High Index (-2.00 to -15.00, up to -2.00 CYL) $315
Transition Lenses Qty
Sunglasses Polarized
SV CR-39 (+3.00 to -4.00, Up to -2.00 CYL) $158SV Polycarbonate (+3.00 to -5.00, up to -2.00 CYL) $178SV 1.60 High Index (Up to -6.00, up to -2.00 CYL) $198SV 1.67 Extra High Index (-2.00 to -15.00, up to -2.00 CYL) $209PAL CR-39 (+3.00 to -4.00, Up to -2.00 CYL) $205PAL Polycarbonate (+3.00 to -5.00, up to -2.00 CYL) $225PAL 1.60 High Index (Up to -6.00, up to -2.00 CYL) $235PAL 1.67 Extra High Index (-2.00 to -15.00, up to -2.00 CYL) $315
Sunglasses Polarized Qty
Coating
UncoatedHard Coat +$20Anti-Glare +$30Super Hydrophobic, Multilayer Scratch Coat +$70Clarion Blue Hydro AR +$80
Special Cutting
Over +6 Base +$40RX over -2.00 CYL +$20Lens Diameter Over 75mm +$20
NOTES
Additional comments or questions:
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	Sphere	Cylinder	Axis	Prism	Add	Base	Decenter
OD (R)
OS (L)

	Sphere	Cylinder	Axis	Prism	Add	Base	Decenter
OD (R)
OS (L)

	Sphere	Cylinder	Axis	BC	DIA
OD (R)
OS (L)

	Seg. HT.	Inset.	Total.	PD.
OD
OS

MIC OPTICAL 丹佛华埠眼镜公司