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PLEASE NOTE: This form is designed for use with Internet Explorer 4+
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 . .
PolyCarbonate
Transition Trilogy
Transition Polycarbonate
*
Coatings/Tints:
Hardcoating
Anti-reflection coat
Amber tint
Grey 10%
Grey 20%
Grey 50%
Grey 75% ONLY CR39
Brown 75% ONLY CR39
Brown 20%
Brown 50%
Brown 10%
G15 Tint 60% ONLYCR39
Grey 60% ONLY CR39
Brown 60% ONLY CR39
*
Styles:
Frame Style
AS Clip
AS Series
Astrospec Rx
BC 101
BC 104
BC 108
Blockbusta
Cosmospec
EX 255
FC 704 - Low Impact
FC 705 - Low Impact
FC 707 - Low & Medium Impact
FC 709
FC 710
FCC06
FCC07
FCS01
FCS02
FCS03
FCS04
FCS06
FCS07
FCS08
FCS09
FCS10
FCT01
FCT02
LOW IMPACT Flytreck 501
LOW IMPACT Ned Kelly 417
Meteor
NTS01
NTS02
NTS07
Razor RX 708
SC2000s - Low & Medium Impact
SG2062
SP01
SP02
SP485
SW01 SnakeWear - Low & Medium Impact
SW02 SnakeWear - Low & Medium Impact
SW06 SnakeWear
Uvex S1
Uvex S2
*
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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