Williams Harris Optical
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The Prescription Lens People
ORDER FORM
Please fill in the following details:
(required fields shown in red)
Company:
Address:
Patient's Reference:
Please select either glass, plastic or polycarbonate:
Glass
Plastic
Polycarbonate
Uncut Lens Order
Right Sph
Right Cyl
Right Axis
Right Prism
Base
Right Prism
Base
Right Add
IN
OUT
UP
DOWN
IN
OUT
UP
DOWN
Left Sph
Left Cyl
Left Axis
Left Prism
Base
Left Prism
Base
Left Add
IN
OUT
UP
DOWN
IN
OUT
UP
DOWN
Seg Size: Right
Left
Height: Right
Left
Inset:
Dist Dec/OC: Right
Left
Tint/Coating:
Frame Type:
Plastic
Metal
Rimless
Supra
Please choose either
Diameter:
Diameter size:
or
ISIS:
Please choose ISIS shape:
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
BOX: A=
B=
DBL=
Special Instructions: