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Melibrad
Las Vegas, NV702-850-6699
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| DATE |
| PATIENT |
 Uncut |
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SPH. |
CYL. |
AXIS |
PRISM |
BASE |
DIST PD. |
NEAR PD. |
| DIST |
R |
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L |
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EYE SIZE/A |
DBL |
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ADD |
HEIGHT |
OC HGT |
BASE CURVE |
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| ADD |
R |
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|
ED |
B |
L |
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| LENS |
POLARIZED |
SV BIF TRI PROG |
LENS COLOR |
| PLASTIC HI INDEX POLY GLASS |
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| FRAME |
ENCL TO COME SUPPLY |
FRAME NAME |
| METAL ZYL NYLON |
| SPECIAL INST. |
FRAME |
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| LENSES |
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| EDGING |
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| OVERSIZE |
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| HIGH POWER |
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| A/R |
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| TINTING |
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| Your Business Name: |
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| Your Name: |
TAX |
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SHIPPING |
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| PHONE NO. |
TOTAL |
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