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Order lenses

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

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

Balancing power preference?

Near vision

Far vision

Equipment used?

Manual Keratometer

Automatic Keratometer

Topography

OCT

Images submitted?

Yes

Corneal abnormalities?

Yes

If yes, please describe

Edema? Dryness? Pinguecula? Pterygium?

Yes

Contact lens wearer?

Yes

OD specs (20/)

OS specs (20/)

Primary activities for lens use?

Computer? Driving? Close work reading? Lifestyle (sports)?

Yes

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

Only current AccuLens account holders may complete this form. Please click here 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

Color

Bitoric Base

Cyl

Drum

Add On Service

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

Color

Bitoric Base

Cyl

Drum

Add On Service

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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