Easyscleral Order Form - Scotlens.

Easyscleral Order Form$^KCC6pB48GUF7R%2026-01-08T16:01:14+00:00

ORDER EASYSCLERAL LENSES

EasyScleral Order Form

Patient Ref / Name

Email

Account ID

Prescriber Name

Purchase Order Number

Lens Trial & Order Parameters

RIGHT LENS OD

Right Trial Lens SAG (µm)

Right Trial Lens Power

Flat Axis Orientation (°)

Over-refraction

OR Sphere

OR Cyl

OR Axis (°)

Calculated Order Parameters

EasyScleral SAG to Order (µm)

Lens Power Sphere

Lens Power Cyl

Lens Power Axis (°)

Scleral Angle

Custom Limbus

Material & Tint

LEFT LENS OS

Left Trial Lens SAG (µm)

Left Trial Lens Power

Flat Axis Orientation (°)

Over-refraction

OR Sphere

OR Cyl

OR Axis (°)

Calculated Order Parameters

EasyScleral SAG to Order (µm)

Lens Power Sphere

Lens Power Cyl

Lens Power Axis (°)

Scleral Angle

Custom Limbus

Material & Tint

Notes/Order Statement

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