OrthoK NightFlex New Order Form

NightFlex New Order Form

Company Name*

Customer code*

Name of the fitter*

E-Mail-Address for requests*

Patient reference*

Order Number

Right Eye

Sphere

Cylinder

Axis

Add

Vertex distance

K flat

Ecc flat

K steep

Ecc steep

Axis flat

HVID

If only mean values for eccentricity are available, please insert the same value in both fields.

Left Eye

Sphere

Cylinder

Axis

Add

Vertex distance

K flat

Ecc flat

K steep

Ecc steep

Axis flat

HVID

Contact lenses

Variant Right

Variant Left

Back surface design Right

Back surface design Left

Material choice Right

Material choice Left

Return options

Urgent order

Only for RELAX Myopia Management:

Pupil diameter Right

Pupil diameter Left

Age of Patient

Additional Information

To že jste člověk prokažte výběrem ikony Strom.

Version 1.1

NightFlex New Order Form

Right Eye

If only mean values for eccentricity are available, please insert the same value in both fields.

Left Eye

Contact lenses

Only for RELAX Myopia Management:

Additional Information

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