Patient Lens Order Dev

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Please fill out the form below for sMap3D Lens Orders.

Date*

MM slash DD slash YYYY

Account #*

PO #

Ordered by:*

First Last

Doctor Order Placed For:

Email*

Enter Email Confirm Email

Patient Name*

Shipping*

UPS Ground

UPS 3rd Day Select

UPS 2nd Day

UPS Overnight

Other

If Other, what Shipping method?*

Right Eye (OD)

New Patient

Duplicate / Re-Order

Remake

None

Left Eye (OS)

New Patient

Duplicate / Re-Order

Remake

None

Right Eye (OD)

Choose a Lens Product and then further define your Right Eye (OD) order below.

If you are submitting with Overall/Total Power only [please enter the total power in the ‘Special Instructions’].
Total power must be vertexed, if applicable and compensated for base curve changes.

Invoice #*

Quantity*

Right Lens*

Choose a Lens Product and then further define design (if available), diameter, and # of lenses in set (if available).

Europa Scleral

Elara Scleral

Jupiter Scleral

K-Max (GP)

SV (GP)

RevGeo (GP)

XL-T (GP)

I-Kone (GP)

OVERALL / TOTAL POWER ONLY

Check this box if you are submitting with Overall/Total Power only [please enter the total power in the ‘Special Instructions’].
Total power must be vertexed, if applicable and compensated for base curve changes.

Europa Fitting Diameter*

16.0

18.0

20.0

Elara Fitting Diameter*

15.5

Jupiter Fitting Diameter*

15.0

15.6

18.2

Fitting Lens Base Curve*

Fitting Lens Base Curve

Fitting Lens Sphere*

Fitting Lens Sphere

Elara Fitting Design*

Standard

Flat

Jupiter Fitting Design*

B (standard)

K (advanced keratoconic)

R (reverse geometry)

S (steep)

F (flat)

I-Kone Fitting Diameter*

9.6

10.4

HydroKone Fitting Design*

Standard

Globus

Pellucid

Diameter*

Diameter

Materials*

Materials

Hydra-PEG

Yes

Base Curve*

Base Curve

Toric Peripheral Curve (Back Surface Toric)

PERIPHERAL CURVE SYSTEM

Standard

Specify

PC Curves assumed to be Standard if no value is specified.

PC1

PC1*

PC2

PC3

PC4

Over Refraction

SPH*

SPH

CYL

CYL*

AXIS

AXIS*

Over Refraction

Presbyopia

ADD

ZONE SIZE

NEAR or DISTANCE

Near

Distance

Left Eye (OS)

Choose a Lens Product and then further define your Left Eye (OS) order below.

Invoice #*

Quantity*

Left Lens*

Choose a Lens Product and then further define design (if available), diameter, and # of lenses in set (if available).

Europa Scleral

Elara Scleral

Jupiter Scleral

K-Max (GP)

SV (GP)

RevGeo (GP)

XL-T (GP)

I-Kone (GP)

OVERALL / TOTAL POWER ONLY

Europa Fitting Diameter*

16.0

18.0

20.0

Elara Fitting Diameter*

15.5

Jupiter Fitting Diameter*

15.0

15.6

18.2

Fitting Lens Base Curve*

Fitting Lens Base Curve

Fitting Lens Sphere*

Fitting Lens Sphere

Elara Fitting Design*

Standard

Flat

Jupiter Fitting Design*

B (standard)

K (advanced keratoconic)

R (reverse geometry)

S (steep)

F (flat)

I-Kone Fitting Diameter*

9.6

10.4

HydroKone Fitting Design*

Standard

Globus

Pellucid

Diameter*

Diameter

Materials*

Materials

Hydra-PEG

Yes

Base Curve*

Base Curve

Toric Peripheral Curve (Back Surface Toric)

PERIPHERAL CURVE SYSTEM

Standard

Specify

PC Curves assumed to be Standard if no value is specified.

PC1

PC1*

PC2

PC3

PC4

Over Refraction

SPH*

SPH

CYL

CYL*

AXIS

AXIS*

Over Refraction

Presbyopia

ADD

ZONE SIZE

NEAR or DISTANCE

Near

Distance

Special Instructions

File 1:

File 2:

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Drop files here or

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Name

This field is for validation purposes and should be left unchanged.