Cherokee Mental Health Online Order Bill-To:*Select3120 - Cherokee Mental Health InstituteShip-To:*Select Clinic3120 - Cherokee Mental Health InstituteOrder Date* MM slash DD slash YYYY Patient InformationName* First Last ID #LensSingle VisionSelect Lens MaterialPolycarbonate: Single VisionPlastic: Single VisionSingle Vision - Reading GlassesSelect Lens MaterialPolycarbonate: Single Vision ReadingPlastic: Single Vision ReadingBi-Focal D-28Select Lens MaterialPolycarbonate: Bi-Focal D-28Plastic: Bi-Focal D-28Tri-Focal 7X28Select Lens MaterialPolycarbonate: Tri-Focal 7X28Plastic: Tri-Focal 7X28ProgressiveSelect Lens MaterialPolycarbonate: Progressive StandardPlastic: Progressive StandardPremium Progressive (Digital)Select Lens MaterialPolycarbonate: Progressive PremiumPlastic: Progressive PremiumDouble Segments (DD)Select Lens MaterialPlastic: DD-28OccupationalSelect Lens MaterialPlastic: Occupational DD-28Plastic: Computer LensPlanoSelect Lens MaterialPolycarbonate: PlanoPlastic: PlanoRight ODSphereCylinderAxisPrismBaseAdd PowerSeg. HeightDist. PDNear PDLeft OSSphereCylinderAxisPrismBaseAdd PowerSeg. HeightDist. PDNear PDFrameFrame Selection*Select Frame MfgTitmus3MOnGuardArtCraft (Hudson)Goggles (clear)Anti-Fog GogglesChoose 3M Frame*Select 3M FrameF9800F9900F6000Eagle650DP720Steel 300Choose ArtCraft Frame*Select ArtCraft FrameH9Choose OnGuard Frame*Select OnGuard FrameOG014OG080OG102OG019OG112SG403TChoose Titmus Frame*Select Titmus Frame70FSC910FC704FC705FC707FC709PC266APC269TR301STR303STR307STR309SEXT2EXT10Frame Color* Gray Brown Frame Color* Antique Brown Dark Gunmetal Frame Color* Matte Clear Matte Tortoise Frame Color* Gold Gunmetal Frame Color* Dark Chrome Walnut Frame Color* Brown Gray Violet Frame Color* Tortoise Antique Pewter Brown Frame Color* Matte Brown Matte Grey Frame Color* Shiny Gray Shiny Brown Frame Color* Dark Brown Matte Dark Gunmetal Frame Color* Dark Grey Brown Amber Frame Color* Gray Black Frame Color* Gray Black Brown Frame Color* Goldtone Gunmetal Frame Color* Antique Pewter Chocolate Chrome Frame Color* Brown Marble Gray Marble Frame Color* Black Tortoise Tortoise Blue Frame Color* Matte Black Bronze Matte Grey Frame Color* Smoke Frame Color* Gray Fade Frame Size* 52.16.140 55.18.145 Frame Size* 53.21.140 56.21.145 Frame Size* 50.19.140 52.19.145 Frame Size* 50.16.145 Frame Size* 49.18.140 51.18.145 Frame Size* 48.16.140 50.16.145 Frame Size* 54.16.140 56.16.140 Frame Size* 56.16.145 58.16.150 Frame Size* 51.19.140 53.19.145 Frame Size* 53.19.140 55.19.145 Frame Size* 53.18.140 55.18.145 Frame Size* 50.16.140 52.16.145 Frame Size* 48.21.140 50.21.145 Frame Size* 48.19.140 50.19.145 52.19.145 Frame Size* 46.19.135 48.19.135 50.19.140 Frame Size* 49.16.125 52.16.130 Frame Size* 50.19.140 52.19.145 Frame Size* 50.21.140 52.21.145 Frame Size* 51.18.140 53.18.140 55.18.145 Frame Size* 52.17.140 54.17.140 56.17.140 58.17.140 Frame Size* 51.17.140 53.17.140 Frame Size* 46.20.145 48.20.145 Frame Size* 50.22.145 52.22.145 Frame Size* 50.13.140 53.15.140 55.15.145 Frame Size* 53.13 56.11 59.13 Frame Size* 51.19.140 53.19.145 Frame Size* 48.20.140 48.22.145 48.24.145 50.22.150 50.24.155 Lens OptionsPhotochromicSelectPhotochromic - BrownPhotochromic - GrayPolarizedSelectPolarized - BrownPolarized - GrayTintSelectSolid TintGradient TintTint ColorSelect Color - LevelGrey - 1Grey - 2Grey - 3Brown - 1Brown - 2Brown - 3Green - 1Green - 2Green - 3Rose - 1Rose - 2Rose - 3UV CoatingSelect MaterialPlastic: UV CoatScratch CoatingSelect MaterialScratch Coat (Plastic only - both sides)Premium Scratch CoatAR CoatingSelect MaterialStandard AR CoatOther ItemsSide Shields*SelectNo Side ShieldsPermanent Side ShieldsClip-On Side ShieldsSilicon Nose PadsSelectSilicon Nose PadsRepair Parts (if available)SelectFrame FrontTemplesOrdering OpticianOptician Name* Phone*Email* Special InstructionsPaymentBill to 3120 - Cherokee MHI $0.00 CAPTCHA
