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Local: 802-295-5933 Phone: 800-410-1618 Fax: 800-468-9301 chadwickoptical@aol.com www.chadwickoptical.com www.hemianopia.org |
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Prism Spectacle & Aspheric Lenticular Order Form
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Date Written |
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Tray # |
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Special Instructions:
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Date Received |
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Invoice Number |
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Bill/Ship Date |
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Doctor:
Address:
Telephone & Ext. |
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Δ Spec Example
AL Example |
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Example |
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Chadwick Optical Inc. P.O. Box 485 1763 Old River Road White River Jct., VT 05001 |
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Qty |
Frame |
Frame Color |
Frame Size |
Lens Material |
Filter Color |
Lens Power |
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1 |
# U23 |
Brown |
48 |
CR39 |
450FV |
+4 w/6Δ |
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1 |
# 2522 |
GM |
46 |
AL |
Flesh |
OD Flesh OS +16 |
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Qty |
Frame |
Frame Color |
Frame Size |
Lens Material |
Filter Color |
Lens Power |
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Total Qty |
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Lens Material |
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CR39-1.49 Index* |
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1.60 Index |
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1.71 Index |
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*AL only in CR39 |
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ADD-ons |
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Flesh |
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Black Out |
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Frosted |
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Contrast Enhancing Filters |