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╔═════════════════════════════════════════════════════╗                                                                                                                   ║Company Name                                        ║                                                                                                                   ║Address                                             ║                                                                                                                   ║City, State, Code     Phone Number        ╔═════════╣                                                                                                                   ╠═══╤══════════╤══════════╤═════╤═════╤═════╣ DECENTER║                                                                                                                   ║D  │   Sph    │   Cyl    │Axis │Prism│Base │ In │Out ║                                                                                                                   ║i  ├──────────┼──────────┼─────┼─────┼─────┼────┼────╢                                                                                                                   ║s R│          │          │     │     │     │    │    ║                                                                                                                   ║t  ├──────────┼──────────┼─────┼─────┼─────┼────┼────╢                                                                                                                   ║a L│          │          │     │     │     │    │    ║                                                                                                                   ║n  ├──────────┼──────────┼─────┼─────┼─────┼────┴────╢                                                                                                                   ║c  │          │          │ Seg │ Seg │Total│  P.D.   ║                                                                                                                   ║e  │Addition  │ Seg Hgt  │Width│Inset│Inset│Far │Near║                                                                                                                   ╟───┼──────────┼──────────┼─────┼─────┼─────┼────┼────╢                                                                                                                   ║S R│          │          │     │     │     │    │    ║                                                                                                                   ║e  ├──────────┼──────────┤     ├─────┼─────┼────┼────╢                                                                                                                   ║g L│          │          │     │     │     │    │    ║                                                                                                                   ╠═══╪══════════╪════════╤═╧═════╪═════╧═════╬════╧════╣                                                                                                                   ║L  │  Size    │A       │B      │ E.D.      ║ Uncut   ║                                                                                                                   ║e  │          │        │       │           ║         ║                                                                                                                   ║n  ├──────────┼────────┼───────┼───────────╩═════════╣                                                                                                                   ║s  │Thickness │ 2MM    │  3MM  │ Other               ║                                                                                                                   ╠═══╧══════════╧════════╪═══════╧═════════════════════╣                                                                                                                   ║ PROGRESSIVE:          │CR39         HI INDEX        ║                                                                                                                   ╟─────────────          ├─────────────────────────────╢                                                                                                                   ║  A.O. OMNI               │S.V     70MM    75MM   80MM  ║                                                                                                                   ║  SUPER NOLINE            │BIF ST-25   ST-28   ST-35    ║                                                                                                                   ║  VIP XL                  │RD SEG      EXEC.            ║                                                                                                                   ║  VIP                     │TRIFOCAL ST7X25    ST7X28    ║                                                                                                                   ║  SMART SEG               │OTHER                        ║                                                                                                                   ╠═══════════════════════╧═════════════════════════════╣                                                                                                                   ║ HARDCOTE        SHIELDCOTE        UV 400            ║                                                                                                                   ╠═════════════════════════════════════════════════════╣                                                                                                                   ║ Frame Name               size           brdg size   ║                                                                                                                   ╠═════════════════════════════════════════════════════╣                                                                                                                   ║ Date            Patient             time wanted     ║                                                                                                                   ║                                                     ║                                                                                                                   ╟─────────────────────────────────────────────────────╢                                                                                                                   ║ Remarks:                                            ║                                                                                                                   ║                                                     ║                                                                                                                   ╟─────────────────────────────────┬──────┬──────┬─────╢                                                                                                                   ║        account: 3222            │LENSES│      │     ║                                                                                                                   ║                                 ├──────┼──────┼─────╢                                                                                                                   ║ N     Name                      │Color │      │     ║                                                                                                                   ║ A     Street Address            ├──────┼──────┼─────╢                                                                                                                   ║ M     City, State, Code         │Frame │      │     ║                                                                                                                   ║ E                               ├──────┼──────┼─────╢                                                                                                                   ║                                 │Misc  │      │     ║                                                                                                                   ╟────────────────┬──────────────┬─┴──────┼──────┼─────╢                                                                                                                   ║ RX:            │Date          │ TOTAL  │      │     ║                                                                                                                   ╚════════════════╧══════════════╧════════╧══════╧═════╝