NightFlex New Order Form

Company Name*

Customer code*

Name of the fitter*

E-Mail-Addresse for requests*

Patient reference*

Order Number

RIGHT Eye

SPH

CYL

Axe

ADD

DVO

K flat

K steep

Axis Kflat

Ecc average

Cornea diameter

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

LEFT Eye

SPH

CYL

Achse

ADD

DVO

K flat

K steep

Axis Kflat

Ecc average

Cornea diameter

CONTACT LENS

Variant Right

Variant Left

Back surface design Right

Back surface design Left

Material choice Right

Material choice Left

Exchange options

Urgent order

Only for RELAX Myopia Management:

Pupil diameter Right

Pupil diameter Left

Age of Patient

Additional Information

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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 LENS

Only for RELAX Myopia Management:

Additional Information

SwissLens

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