Indian Health Services – Cheyenne River Service Unit Bill-To/Ship-To:*Cheyenne River Service UnitOrder Date* MM slash DD slash YYYY Patient InformationName* First Last Phone*Email Right ODSphereCylinderAxisPrismBaseAdd PowerSeg. HeightDist. PDNear PDLeft OSSphereCylinderAxisPrismBaseAdd PowerSeg. HeightDist. PDNear PDFrameSelect Package*Select PackageChildren/Youth PackageAdult PackageSafety PackageOther/Replacement PartsSelect Frame Group*Select Frame GroupGreen, Lime, BlueRed - Modz KidsRed - MODZRed - Genevieve ParisRed - Giovani Di VeneziaRed - Modz SunzYellow - GB+Yellow - Genevieve BoutiqueYellow - B.M.E.C.Black - TitaniumSelect Frame - Youth*Select Frame GroupGreen, Lime, BlueRed - Modz KidsRed - MODZSelect Frame - Safety*Select Frame GroupSafety FrameSelect Frame Group - ReplaceSelect Frame GroupGreen - Modern MetalsLime - Plastics IGreen - Plastics IIBlue - Modern TimesRED GroupYELLOW GroupBLACK GroupSafetyFrame Information*NameColorEye SizeBridge SizeTemple SizeFrame Information - ReplaceNameColorEye SizeBridge SizeTemple SizeLensSingle VisionSelect Lens MaterialPolycarbonate (SV)Plastic (SV)Aspheric (SV)Hi-Index 1.60 (SV)Glass (SV)Glass - PGX (SV)Glass - Thin & Dark (SV)Hi-Index 1.67 (SV)Hi-Index 1.74 (SV)Single Vision - Lens OnlySelect Lens MaterialPolycarbonate (SV)Plastic (SV)Hi-Index 1.60 (SV)Glass (SV)Glass - PGX (SV)Glass - Thin & Dark (SV)Hi-Index 1.67 (SV)Hi-Index 1.74 (SV)Bi-Focal (FT-28)Select Lens MaterialPolycarbonate (BF)Plastic (BF)Aspheric (BF)Hi-Index 1.60 (BF)Glass (BF)Glass - PGX (BF)Glass - Thin & Dark (BF)Hi-Index 1.67 (BF)Bi-Focal (FT-28) - Lens OnlySelect Lens MaterialPolycarbonate (BF)Plastic (BF)Hi-Index 1.60 (BF)Glass (BF)Glass - PGX (BF)Glass - Thin & Dark (BF)Hi-Index 1.67 (BF)Tri-Focal (7x28)Select Lens MaterialPolycarbonate (TF)Plastic (TF)Hi-Index 1.60 (TF)Glass (TF)Glass - PGX (TF)Glass - Thin & Dark (TF)Tri-Focal (7x28) - Lens OnlySelect Lens MaterialPolycarbonate (TF)Plastic (TF)Hi-Index 1.60 (TF)Glass (TF)Glass - PGX (TF)Glass - Thin & Dark (TF)ProgressiveSelect Lens MaterialPolycarbonate (Prog)Plastic (Prog)Aspheric (Prog)Hi-Index 1.60 (Prog)Glass (Prog)Glass - PGX (Prog)Glass - Thin & Dark (Prog)Hi-Index 1.67 (Prog)Hi-Index 1.74 (Prg)Progressive - Lens OnlySelect Lens MaterialPolycarbonate (Prog)Plastic (Prog)Hi-Index 1.60 (Prog)Glass (Prog)Glass - PGX (Prog)Glass - Thin & Dark (Prog)Hi-Index 1.67 (Prog)Hi-Index 1.74 (Prg)Add-On'sAnti-Reflective CoatingSelectStandard ARPremium ARUltra Premium AR w/ dip coatTransitionsSelectTransitionsTransitions XTRA DarkTintSelectSolidGradientTint Color* Premium Scratch CoatSelectPremium Scratch CoatSlab-OffSelectSlab-OffMirror CoatingSelectMirror CoatingBlue Light Blocker w/ dip coatSelectBlue Light Blocker w/ dip coatRimlessSelectRimlessRoll & PolishSelectRoll & PolishOver 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/OpticianName PhoneSpecial InstructionsShipping PaymentTotal Amount Due $0.00 IHS PaysPatient PaysMoney Order NumberCAPTCHA