Indian Health Services - Cheyenne River Service Unit

Bill-To/Ship-To:*

Order Date*

Patient Information

Name*

First Last

Phone*

Email

Right OD

Sphere	Cylinder	Axis	Prism	Base	Add Power	Seg. Height	Dist. PD	Near PD

Left OS

Sphere	Cylinder	Axis	Prism	Base	Add Power	Seg. Height	Dist. PD	Near PD

Frame

Select Package*

Select Frame Group*

Select Frame - Youth*

Select Frame - Safety*

Select Frame Group - Replace

Frame Information*

Name	Color	Eye Size	Bridge Size	Temple Size

Frame Information - Replace

Name	Color	Eye Size	Bridge Size	Temple Size

Lens

Single Vision

Single Vision - Lens Only

Bi-Focal (FT-28)

Bi-Focal (FT-28) - Lens Only

Tri-Focal (7x28)

Tri-Focal (7x28) - Lens Only

Progressive

Progressive - Lens Only

Add-On's

Anti-Reflective Coating

Transitions

Tint

Tint Color*

Premium Scratch Coat

Slab-Off

Mirror Coating

Blue Light Blocker w/ dip coat

Rimless

Roll & Polish

Over Power Charges

Prism: add $2.00 per diopter PER EYE
Sphere: + or - 4.12 and above (add $2.00 per diopter)
Cylinder: + or - 3.12 and above (add $2.00 per diopter)

Doctor/Optician

Name

Phone

Special Instructions

Shipping

Payment

Total Amount Due

$0.00

IHS Pays

Patient Pays

Money Order Number

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