Iowa Medical Classification Center Online Order Bill-To:*Select3007 - Iowa Medical Classification CenterShip-To:*Select Clinic3007 Iowa Medical Classification CenterOrder Date* MM slash DD slash YYYY Patient InformationName* First Last ID# FrameFrame Selection*Select Frame Mfg3MGoggles (clear)Anti-Fog GogglesChoose 3M Frame*Select 3M FrameF9800F9900Frame Color* Smoke Frame Size* 46.20.145 48.20.145 Frame Size* 50.22.145 52.22.145 LensSingle VisionSelect Lens MaterialPolycarbonate: Single VisionPlastic: Single VisionBi-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 PDLens OptionsTransitionsSelectPhotochromic - BrownPhotochromic - GrayPolarizedSelectPolarized - BrownPolarized - GrayTintSelectSolid TintGradient TintTint ColorSelect Color - LevelGrey - 1Grey - 2Grey - 3Brown - 1Brown - 2Brown - 3Green - 1Green - 2Green - 3Rose - 1Rose - 2Rose - 3UV CoatingSelect MaterialPlastic: UV CoatPoly: UV CoatScratch CoatingSelect MaterialScratch Coat (Plastic only - both sides)Premium Scratch CoatAR CoatingSelect MaterialStandard AR CoatOther ItemsSilicon Nose PadsSelectSilicon Nose PadsRepair Parts (if available)SelectFrame FrontTemplesDOUBLE 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/OpticianName PhoneSpecial InstructionsPaymentBill to: 3007Iowa Medical Classification CenterCAPTCHA