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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 . .
PolyCarbonate Polarised
Transition Polycarbonate
PolyCarbonate
Transition Trilogy
*
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
BC 101
BC 104
BLAYDZ
Bolle Slide
CYPHA
FC 704 - Low Impact
FC 705 - Low Impact
FC 707
FC 708
FC 709
FC 710
FCC06
FCC07
FCS01
FCS02
FCS03
FCS04
FCS06
FCS07
FCS08
FCS10
FCT01
FCT02
LOW IMPACT Flytreck 501
Meteor
NEO
NTS01
NTS02
NTS07
SG2062
Slim
SP01
SP02
SW02 SnakeWear
SW06 SnakeWear
SW07 - Frame only
SW07 with Insert & Strap
Uvex S1
Uvex S2
ZION
*
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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