Lawton Service Unit Online Ordering Portal Bill-To:*Lawton IHSShip-To:*Lawton IHCAnadarko IHCCarnegie IHCOrder Date* MM slash DD slash YYYY Patient InformationName* First Last Phone*Email Chart #* FrameFrame Group*Select Frame GroupModern Blue, Green, Lime Green)Up-Grade RED (Modern)Up-Grade YELLOW (Modern)Frame Information*NameColorEye SizeBridge SizeTemple SizeLensSingle VisionSelect Lens MaterialPolycarbonate - Single VisionPlastic - Single VisionBi-FocalSelect Lens MaterialPolycarbonate - BifocalPlastic - BifocalTri-FocalSelect Lens MaterialPolycarbonate - TrifocalPlastic - TrifocalHiddenProgressiveSelect Lens MaterialPolycarbonate - ProgressivePlastic - ProgressiveHiddenEyezen+Select Lens MaterialEyezen+1 (0.40 D)Eyezen+2 (0.60 D)Eyezen+3 (0.85 D)Includes Blue Light Blocker in lensRight ODSphereCylinderAxisPrismBaseAdd PowerSeg. HeightDist. PDNear PDLeft OSSphereCylinderAxisPrismBaseAdd PowerSeg. HeightDist. PDNear PDTintSelect Color - LevelTint Grey - 1Tint Grey - 2Tint Grey - 3Tint Brown - 1Tint Brown - 2Tint Brown - 3Tint Green - 1Tint Green - 2Tint Green - 3Tint Rose - 1Tint Rose - 2Tint Rose - 3Tint Blue - 1Tint Blue - 2Tint Blue - 3AR CoatingSelectStandard ARPremium ARHiddenTransitionSelectPhotochromicXTRA Active TransitionHiddenBlue FilterSelectBlue Filter (in lens - clear appearance)HiddenBlue BlockerSelectBlue Safe COATING (w/ AR & Prem Scratch Coat)Doctor/OpticianName PhoneSpecial InstructionsPaymentTotalCredit CardPlease check if you have activated a Stripe feed for your form. CAPTCHA
