Phone: 800-410-1618

Fax: 800-468-9301

chadwickoptical@aol.com

www.chadwickoptical.com

www.hemianopia.org

Rx ONLY

Peli Lens™—CR39 3mm thick

Order Form

Date Written

Tray #

Organization:

 

 

 

 

 

 

 

Patient:

Frame   Specifications:             

Manufacturer:___________________________

 

Style:_________________Color:____________

 

A/DBL_____/_____ B/ED____/_____

 

(    )

(    )

(    )

Distance

Near

TINT:

 

 

 

 

NO AR

NO Transitions

Special Instructions:

 

 

 

 

 

Date Received

Invoice Number

Bill/Ship Date

 

Peli Lens™

Specifications

……………………...

Always BASE OUT unless noted in special instructions

 

( please see illustration below)

 

Lower Height (X) ________   

 

Separation (Z)     ________

 

Upper Height (Y) ________

Vertical Frame  dimension: Must be 36MM or greater

Vertical Frame  dimension: Must be 43MM or greater

Available with Upper Prism Only

Spectacle Lens Style

Full metal w/nose pads is recommended

NO       RIMLESS

       /

      /

PD

Supply

Enclosed

To Come

Check one

(  ) 40Δ Horizontal

 

(  ) 57Δ Horizontal

 

(  ) 57Δ Oblique Vertex _______

                         (vertex required)

 Doctor:

 

 Address:

 

 Telephone & Ext.

Lens with Peli Δ

(check one)

 

(  )  OD

 

(  )  OS

Final Fitting Positions:

 Y – X = Z or X + Z = Y

 X = Lower Height

 Y = Upper Height

 Z = Separation

Chadwick Optical Inc.

P.O. Box 485

1763 Old River Road

White River Jct., VT  05001