Laser Eyewear Information Sheet
Patient Name or Job/Tray number:___________________________________________
Laser # 1 Laser # 2 Laser #3
Laser Type: _________ _________ _________
Laser Class: _________ _________ _________
Wavelength (nanometers): _________ _________ _________
Power CW (max): _________ _________ _________
Power Pulsed (joules): _________ _________ _________
Pulse Length (sec): _________ _________ _________
R
Notes: If prescription eyewear is required, please complete the section below, and attach a copy of the prescription. The prescription should be less than two years old.
Pupillary distance(s) are REQUIRED for all prescription eyewear. We cannot make prescription eyewear without your PD's! If your current prescription does not have your PD written on it, please take your prescription to any optometrist or dispenser and have your PD measured.
Sphere Cylinder Axis Prism Base
Right Eye ________ ________ _____ ______ ______
Left Eye ________ ________ _____ ______ ______
Multifocals Add Power Height
Right Eye ______ ______
Left Eye ______ ______
Multifocal Style: D28 (bifocal) 7 x 28 (trifocal) Progressive (CO2 only)
Pupilliary Distance (Far):______ Pupillary Distance (Near):_____ (multifocals only)
Frame Name:_________________ Frame Color:_________________
Frame Sizes A box:______ B box: _______ ED: _________ DBL: _________
FAX to: 320-253-1239 or e-Mail to: sales@auralens.net
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