South Jordan, UT
801-923-3935

Lab Order Portal

Book Appointment

Lab Order Portal

Ordering Practice

Practice Name*

Doctor Name*

Office Email* (for confirmation)

Office Phone

Account Number

Patient Information

Patient Name*

Patient ID / Chart #

Date of Birth

Order Priority*

Frame Information

Frame Source*

Frame Brand

Frame Model

Frame Color

Frame Measurements (A / B / DBL / Temple)

Prescription

	Sphere	Cyl	Axis	Prism	Base
OD
OS

Add Power (if needed)

PD (Mono or Binocular)

Seg / Fitting Height

Lens Options

Lens Type*

Material*

Coatings and Treatments AR coating
Super hydrophobic
Blue light filter

Light Management Photochromic
Polarized
Tint details

Delivery and Rush

Delivery Method*

Needed by date

Special Instructions