ACCOUNT NAME
PATIENT LAST NAME, FIRST
DATE
ORDER SUBMITTED BY
SHIPPING
STANDARD UPS
RUSH ORDER ($25)
EXPEDITED SHIPPING ($$)
DROP SHIP PATIENT ($25)
DROP SHIP ADDRESS
ENCHROMA FRAME NAME
EYESIZE
COLOR
PATIENT'S OWN FRAME
BRAND & MODEL
EYESIZE
COLOR
LENSES
UNCUT LENSES
PLANO
SINGLE VISION
FF SINGLE VISION
PROGRESSIVE
FF PROGRESSIVE
ENCHROMA Cx SERIES
Cx SUN
Cx2 SHADE
Cx1 INDOOR
Cx SUN SP
Cx2 SHADE SP
Cx1 INDOOR DT
ENCHROMA Cx LOW VISION
Cx4 A1 (8%T)
Cx4 A2 (2%T)
Cx4 A3 (1%T)
PATIENT'S OWN FRAME EDGING
ZYL/METAL
RIMLESS
SEMI-RIMLESS
METAL GROOVE
SAFETY
FRAME DIMENSION
A
B
ED
DBL
LENS BASE CURVE
2 BASE
4 BASE
6 BASE
8 BASE
LAB CHOOSE
FRAME SHAPE
Frame Shape: Select from shapes below.
1
2
3
4
5
6
7
8
9
10
11
12
13
PRESCRIPTION
SPHERE
CYL
AXIS
RIGHT
LEFT
ADD
PRISM
BASE DIRECTION
RIGHT
LEFT
PD
FITTING
HEIGHT
POSITION OF WEAR
VERTEX
TILT
WRAP ANGLE
FREE FORM SINGLE VISION AND PROGRESSIVE
Optimized Lenses are compensated for an average vertex, tilt and wrap
Customized Lenses are compensated for actual vertex, tilt and wrap
CHOOSE A FREE FORM PROGRESSIVE
EXPANSE, BALANCED DESIGN, DISTANCE, MID-RANGE, NEAR
CAPTAIN, WIDE DISTANCE AND MID-RANGE
IMMEDIA, WIDE DISTANCE AND NEAR
SLEEK, SHORT CORRIDOR
DISPLAY 6.5, IN-OFFICE PROG, CLEAR TO 6.5 FT
SPECIAL INSTRUCTIONS
FAX OR EMAIL TO ENCHROMA LAB SERVICES
EMAIL
labservices@enchroma.com
FAX
510-217-3589
ENCHROMA INC.
2629 7TH STREET
BERKELEY, CA 94710
510-771-8914