ENCORE OPTICAL SUPPLY
4519 162nd Street, Flushing, NY 11358
P: 718-888-1490   FAX: 718-888-7739
Website: www.order-encore.com
Name:
Acct #:
Patient: Date: / /
SPHERE CYLINDER AXIS ADD SEG. HGT. O.C HGT.
R
L
PD TINTS
GreyBrown
Color %
PRISM BASE CURVE DISTANCE NEAR
R
L
EYE SIZE DBL B BOX E.D. PHOTOCHROMIC SPIN

LENSE STYLE CORRIDOR MATERIAL


FREE FORM PAL

AR/SRC COATING POLARIZED COLOR



FRAME
SPECIAL INSTRUCTION