Thundercloud LLC Optical Rx order form
To be completed by an eye care professional.
Account Name: Account #:
Patient Name:

Lens Type

Style

Plastic Tints

Coatings
Plastic
Glass
Polycarbonate
Spectralite
High Index
           Plastic


Index of
      Refraction

ZEISS

UNCUT

 Single Vision
Asperic
Progressive
            (specify)
     
        
        BIFOCAL
FT  25  28  35  

      TRIFOCAL
FT  25  28  35  

        OTHER
  

 Tint     Clear
Color:       

Solid  Gradient
 Double Gradient
 UV
 Sample Enclosed

Gry

Brn
Transitions
XtrActive
Polarized

Glass Color
Pink 1 2
Gray 1 2 3
PGX PBX PGTD
Other 

Super Arx
             Anti-Reflective
Scratch Coat
Mirror Coat
DBL Grad Mirror
UV (Glass)
 Other


   Name / Description

Miscellaneous
Roll & Polish
Edge Polish
Safety Monogram 3.0
Non Industrial 3.0

Frame Information

Doctor
 Patient
 Vision Value
 Enclosed
 To Come

  Lenses Only (circumference)
Please provide circumference.

Manufacturer Name Color Shape
Sphere Cylinder Axis Prism Special Instructions
R
L
Add Seg Height

PD
R Dist Near
L


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