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Account #
Patient Name:
Date: MM / DD / YY

 

   
O.D
O.S
SAG depth value:  
Arrow
Arrow
     
 
 
Midperipheral / limbal:
 
 
 

Standard
Standard
 
or
or
 
Increased
Increased
 
or
or
 
Decreased
Decreased
     
 
 
Power:  
Arrow
Arrow
             
Diameter:      
             
Fenestration:      

 

 

Note: Attering the mid-peripheral / limbal clearance zone value, changes the base curve profile. Please ensure your over-refraction was performed with the correct mid-peripheral / limbal zone clearance value in situ. If not, please ensure the lens power is compasated accordingly. Increasing or lowering sag depth value will not affect power.

Fenestration: When specified, lenses are fenestrated once. If more than one fenestration is required please call Blanchard for details.

You can fax your order at 1-603-627-3280