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AccuLens recommends completing forms on a desktop computer rather than a mobile device.
Please confirm all patient data before submitting your order.
Your information
Your name
(required)
Your position
(required)
Already have an account?
Yes
Account number
Account name
No
Office name
Phone number
New order or remake?
New order
Remake
Invoice number
Patient Information
Name
(required)
Occupation
(required)
K-values
OD
(required)
OS
(required)
Spectacle RX / Manifest RX
OD
(required)
20/?
(required)
OS
(required)
20/?
(required)
Patient's best visual outcome?
(required)
Cornea Diameter
OD
(required)
OS
(required)
Multifocal?
Yes
Patient age
Add power
Pupil diameter OD
Pupil diameter OS
Dominant eye?
Right
Left
No
Balancing power preference?
Near vision
Far vision
Equipment used?
Manual Keratometer
Automatic Keratometer
Topography
OCT
Images submitted?
Yes
No
Corneal abnormalities?
Yes
No
If yes, please describe
Edema?
Dryness?
Pinguecula?
Pterygium?
Yes
No
Yes
No
Yes
No
Yes
No
Contact lens wearer?
Yes
No
OD specs (20/)
OS specs (20/)
Primary activities for lens use?
Computer?
Driving?
Close work reading?
Lifestyle (sports)?
Yes
No
Yes
No
Yes
No
Yes
No
Patient notes
Describe anything else important to the empirical build
Shipping instructions
Standard
Overnight
Acknowledgement
(required)
I understand that all EasyFit Lifestyle empirical orders are manufactured directly from the date entered on this form. I believe information submitted to be accurate for that above referenced patient.
Enter the following information to request a trial lens set.
Already have an account?
Yes
No
Only current AccuLens account holders may complete this form. Please
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to request a new account.
If yes, account number
(required)
Account name
(required)
Your name
(required)
New order or exchange?
New order
Exchange
Patient name
(required)
S H I P P I N G I N F O R M A T I O N
Ship to?
Office / Drop Ship
Mail to patient
Patient Address
(required)
L E N S O D I N F O R M A T I O N
Lens design
Corneal GP
Select lens
Single Vision
Horizon
Bitoric
Front Toric
Multifocal GP
Select lens
Accent
Accufocal
Accufocal Plus
Clarity Plus
Clarity Plus High Add
Clarity Plus Ext Add
Specialty GP
Select lens
Accucone K
Horizon Cone
Comfortperm
New Vision
Aquaflow
Scleral Lens
Select lens
Maxim
Maxim Toric
Maxim Plus
Maxim Plus Toric
EasyFit
EasyFit Toric
EasyFit Plus
EasyFit Plus Toric
Comfort SL
Comfort SL Toric
Comfort SL Plus
Comfort SL Plus Toric
BC - Flat/Steep
Power / Cyl / Axis
Diam
Material
Select...
Optimum Comfort
Optimum Extra
ONSI 56
Tyro 97
Optimum Classic
Optimum Extreme
Hybrid FS
Optimum HR 1.53
SGP
SGP II
SGP III
Valeant (Boston ES)
Valeant (Boston EO)
Valeant (Boston XO)
Valeant (Boston XO2)
Valeant (Paragon HDS)
Valeant (ParaPerm O2)
Valeant (FluroPerm 30)
Valeant (FuroPerm 60)
Color
Select...
Blue
Green
Clear
Dark Blue
Dark Green
Light Blue
Gray
Brown
Bitoric Base
Cyl
Drum
Add On Service
Select...
Aquawet Plasma
Notch
Truncation
Multifocal
Fenestration
Prism
K's
Spec RX - Sphere / Cyl / Axis
Multifocal Add
Dominant Eye
Pupil Diam
HVID
SEG Dia/Height
Enhancement
Prism
L E N S O S I N F O R M A T I O N
Lens design
Corneal GP
Select lens
Single Vision
Horizon
Bitoric
Front Toric
Multifocal GP
Select lens
Accent
Accufocal
Accufocal Plus
Clarity Plus
Clarity Plus High Add
Clarity Plus Ext Add
Specialty GP
Select lens
Accucone K
Horizon Cone
Comfortperm
New Vision
Aquaflow
Scleral Lens
Select lens
Maxim
Maxim Toric
Maxim Plus
Maxim Plus Toric
EasyFit
EasyFit Toric
EasyFit Plus
EasyFit Plus Toric
Comfort SL
Comfort SL Toric
Comfort SL Plus
Comfort SL Plus Toric
BC - Flat/Steep
Power / Cyl / Axis
Diam
Material
Select...
Optimum Comfort
Optimum Extra
ONSI 56
Tyro 97
Optimum Classic
Optimum Extreme
Hybrid FS
Optimum HR 1.53
Valeant (Boston ES)
Valeant (Boston EO)
Valeant (Boston XO)
Valeant (Boston XO2)
Valeant (Paragon HDS)
Valeant (ParaPerm O2)
Valeant (FluroPerm 30)
Valeant (FuroPerm 60)
Color
Select...
Blue
Green
Clear
Dark Blue
Dark Green
Light Blue
Gray
Brown
Bitoric Base
Cyl
Drum
Add On Service
Select...
Aquawet Plasma
Notch
Truncation
Multifocal
Fenestration
Prism
K's
Spec RX - Sphere / Cyl / Axis
Multifocal Add
Dominant Eye
Pupil Diam
HVID
SEG Dia/Height
Enhancement
Prism
Special Instructions
I have verified all of my entries prior to submitting this request.
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