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* Standard Rush Super Rush Frame Information Frame Source* Patient own frame Lab inventory frame 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* Single vision Progressive FT 28 Computer / office Other (describe in notes) Material* Polycarbonate Trivex 1.60 1.67 1.74 Coatings and Treatments AR coating Super hydrophobic Blue light filter Light Management Photochromic Polarized Tint details Delivery and Rush Delivery Method* Ship to office Hold for pick up Needed by date Special Instructions Submit Lab Order