Online Order SECOND PAIR – IHS Oklahoma – ALL PATIENT PAY Bill-To:*IHS Oklahoma - SECOND PAIR (2724) - ALL PATIENT PAYShip-To:*SelectClinton IHC - 2720El-Reno IHC - 2730Order Date* MM slash DD slash YYYY Patient InformationName* First Last Phone*Email Chart #* FrameFrame Group*Select Frame GroupModern Designer (Blue, Green, Lime Green)Up-Grade RED (Modern)Up-Grade YELLOW (Modern)SafetySports & RecPediatricSelect Pediatric Frame*Select FrameBaby LuxBaby Lux2Baby OneBaby One 44Baby ZeroEvaMaxi BabyMaxi Baby2Mini BabyNew Baby1New Baby2New Baby3New Baby4Nicki 48Nicki 50Nicki 53Frame Information*NameColorEye SizeBridge SizeTemple SizeFrame Color*ColorLensSingle VisionSelect Lens MaterialPolycarbonate - Single VisionPlastic - Single VisionHi-Index w/ AR - Single Vision (4101F)Bi-FocalSelect Lens MaterialPolycarbonate - BifocalPlastic - BifocalHi-Index w/ AR - Bifocal (4101F)Tri-FocalSelect Lens MaterialPolycarbonate - TrifocalPlastic - TrifocalHi-Index w/ AR - Trifocal (4101F)ProgressiveSelect Lens MaterialPolycarbonate - ProgressivePlastic - ProgressiveHi-Index w/ AR - Progressive (4101F)Eyezen+Select Lens MaterialEyezen+1 (0.40 D)Eyezen+2 (0.60 D)Eyezen+3 (0.85 D)Includes Blue Light Blocker in lensSafety GlassesSelectSingle Vision - Polycarbonate (Safety)Bi-Focal - Polycarbonate (Safety)Progressive - Polycarbonate (Safety)Sports & RecreationSelectSingle Vision - PolycarbonateBi-Focal - PolycarobonateRight 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 - 3Tint Yellow - 1Tint Yellow - 2Tint Yellow - 3AR CoatingSelectStandard ARPremium ARTransitionSelectPhotochromicXTRA Active TransitionMiscellaneousSelectPrism under 4 Diopters (per pair)Roll (per pair)PolishBlue FilterSelectBlue Filter (in lens - clear appearance)Blue BlockerSelectBlue Safe COATING (w/ AR & Prem Scratch Coat)Doctor/OpticianName PhoneSpecial InstructionsPaymentTotalCredit CardCard Details Cardholder Name CAPTCHA
