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An asterik (*) indicates a compulsory field.
Patient Details
New Patient
Existing Patient
Order Number:
Patients Name: *
Company Name: *
Company Suburb/Depot:
MSRX Agent:
Employee No:
Prescription Details
Right Sphere:
+
-
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
5.25
5.50
5.75
6.00
6.25
6.50
6.75
7.00
7.25
7.50
7.75
8.00
8.25
8.50
8.75
9.00
9.25
9.50
9.75
10.00
10.25
10.50
10.75
11.00
11.25
11.50
11.75
12.00
12.25
12.50
12.75
13.00
13.25
13.50
13.75
14.00
14.25
14.50
14.75
15.00
Right Cyl:
-
+
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
Right Axis:
[0 - 180]
Right Prism:
Right Prism Direction:
Left
Sphere:
+
-
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
5.25
5.50
5.75
6.00
6.25
6.50
6.75
7.00
7.25
7.50
7.75
8.00
8.25
8.50
8.75
9.00
9.25
9.50
9.75
10.00
10.25
10.50
10.75
11.00
11.25
11.50
11.75
12.00
12.25
12.50
12.75
13.00
13.25
13.50
13.75
14.00
14.25
14.50
14.75
15.00
Left Cyl:
-
+
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
Left Axis:
[0 - 180]
Left
Prism:
Left Prism
Direction:
Add:
0
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
Distant PD:
Near PD:
Heights:
DOC:
Material:
Choose a Lens Material . .
Transition CR39
CR39
PolyCarbonate
Transition Polycarbonate
Transition Trilogy
Trilogy
*
Coatings/Tints:
Hardcoating
Anti-reflection coat
Amber tint
Grey 10%
Grey 20%
Grey 50%
Grey 75%
Brown 75%
Brown 20%
Brown 50%
Brown 10%
G15 Tint 60%
Grey 60%
Brown 60%
*
Styles:
Frame Style
508
554
557
Astrospec Rx
BC 101
BC 102
BC 103
BC 104
BC 107
BC 108
BC 109
BC 115
Blockbusta 605 - Low & Medium Impact
Cosmospec
EX 255
EX T5
EX TS1
FC 704 - Low Impact
FC 705 - Low Impact
FC 706 - Low & Medium Impact
FC 707 - Low & Medium Impact
FC 709
FC 710
Foreman 308
Meteor
PC 250
PC 250sw
PC 251
PS/AS Series
Razor 708
Safety 06
SC2000s - Low & Medium Impact
Sportstyle Rx
Stormstrike Goggle
SW01 SnakeWear - Low & Medium Impact
SW02 SnakeWear - Low & Medium Impact
SW06 SnakeWear
TR 301s
TR 306s
Uvex S1
Uvex S2
Uvex S3
Uvex T1
Uvex T2
*
Lens Types:
*
Sizes:
*
Frame Colour:
Patient Facial Photo
Photo
NOTE: Facial Photo is to fill all of photo with patient looking directly at camera and wearing the frame selected above.
Special Instructions
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