Iowa Medical Classification Center Online Order

Bill-To:*
Ship-To:*
Order Date*
MM slash DD slash YYYY
Patient Information
Name*
First Last
ID#
Frame
Frame Selection*
Choose 3M Frame*
Frame Color*
- Smoke
Frame Size*
- 46.20.145
- 48.20.145
Frame Size*
- 50.22.145
- 52.22.145
Lens
Single Vision
Bi-Focal D-28
Tri-Focal 7X28
Progressive
Premium Progressive (Digital)
Double Segments (DD)
Occupational
Plano
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
Lens Options
Transitions
Polarized
Tint
Tint Color
UV Coating
Scratch Coating
AR Coating
Other Items
Silicon Nose Pads
Repair Parts (if available)
DOUBLE CHECK RX*
- Did you enter the entire prescription correctly?
Bi-Focal or Progressive CHECK?*
- Seg Height and Add Power are REQUIRED for BF/Progressive
Single Vision Readers CHECK?*
- If you are ordering Single Vision readers, please indicate this in the notes section.
Doctor/Optician
Name
Phone
Special Instructions
Payment
Bill to: 3007
Iowa Medical Classification Center
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Patient Information