Optical Lab Order Form PDF Details

When filling out an Optical Lab Order form, it's important to pay attention to various details that ensure eyewear is crafted to meet specific requirements. This comprehensive document captures essential information, from the date of service and patient details to precise specifications for lenses and frames. Each section, including the patient or parent's education on the advantage of impact-resistant polycarbonate lenses and the choice between frame only or lenses only orders, plays a critical role in customizing eyewear. Specifications such as the type of job, segment type, material choices, and special instructions are crucial for creating the perfect fit and vision correction. Additionally, the form covers financial aspects like Medicaid ID, total paid, and warranty options, alongside authorization numbers for regulated Medicaid and PeachCare. Furthermore, details like the frame information if only lenses are ordered, including color, dimensions, and desired treatments like tint or anti-glare properties, highlight the form's role in ensuring each pair of glasses is tailored to the patient's needs. This level of detail, found at locations like the Atlanta Eye Center with various contact points listed for convenience, illustrates the meticulous process involved in ordering through Custom Optical Laboratories, Inc., indicating a thorough approach to providing personalized eyewear solutions.

QuestionAnswer
Form NameOptical Lab Order Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesWellcare, bard optical fillable forms, BC, UV400

Form Preview Example

** Fax Date__________________ Initials ________

Howell Mill

Gresham Road

1801 Howell Mill Rd NW

2427 Gresham Rd SE

Suite

100

Atlanta, GA 30316

Atlanta, GA 30318

(404) 244-3990

(404)

352-3414

Act# 5260

Act# 2700

ATLANTA EYE CENTER

Avondale

Marietta

3580 Memorial Dr

1785 Cobb Pkwy South

Decatur, GA 30032

Marietta, GA 30060

(404) 284-0701

(770) 955-5019

Act# 2660

Act# 2680

 

 

 

 

 

 

 

 

**DATE OF SERVICE (required)

 

TRAY #

 

**Medicaid ID # (required or write N/A)

TOTAL PAID $

 

 

 

 

 

 

Patient or Parent were educated

 

JOB TYPE

 

PATIENT LAST NAME

PATIENT FIRST NAME

about the option of impact

 

Frame Only

 

 

resistant polycarbonate lenses.

 

Lenses Only

 

 

 

 

 

 

 

Optician initial here:

 

Contact Name and Phone Number

 

 

New Job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEG TYPE (circle)

 

 

 

MATERIAL (circle)

S/V - Single Vision

 

 

 

Plastic

 

 

 

 

 

 

 

 

 

Add Transitions

 

 

 

 

 

 

 

FlatTop28

 

 

Progressive

Polycarb (-5.25/+4.00)

 

Brown

 

 

 

(requires Monocular PD)

 

 

 

 

 

 

 

Grey

SPECIAL

 

 

TYPE

 

Hi Index (1.67)

 

 

 

 

 

 

BC

SPH

CYL

AXIS

DIST PD

NEAR

Seg Height

ADD

R

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

DECENTRATION

OC

PRISM

BASE

THICKNESS

INSET

TOTAL

R

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

IN

OUT

 

 

 

SPECIFY

 

 

INSTRUCTIONS or SPECIAL NOTES:

 

Age*

 

Circle One: Required*

 

 

 

 

 

 

 

 

 

 

 

PeachState

Wellcare

 

 

 

 

 

 

 

 

 

 

 

Amerigroup

Paid Replacement

 

 

 

 

 

 

 

 

 

 

Warranty

 

 

AUTHORIZATION NUMBER:

 

 

 

 

 

 

*Reg. Medicaid and PeachCare go to GCI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRAME: If lenses only, you must right down the frame information

 

COLOR:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

B

 

ED

 

BRIDGE

 

TEMPLE

 

FPD

LENS CIRC

MARK UP

 

 

 

 

 

 

 

 

TINT

Y

N PICK COLOR & STRENGTH

 

 

TREATMENTS

 

SPECIAL

SOLID

10%

GRY

ROS

G15

 

 

 

 

 

 

 

 

 

or

50%

BRN

TAN

PGX

 

UV400 Protection

 

 

 

 

 

 

 

 

 

 

Roll and Polish

GRADIENT

80%

PNK

BLU

PBX

 

 

 

 

 

 

 

 

 

A/R-Anti-Glare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOM OPTICAL LABORATORIES, INC. 6406 Highway 85, Riverdale, GA 30274 | Tel (770) 997-3344 | Fax (770) 994-0038 |

FAX HERE FIRST: AEC Glasses Fax Line (404) 393-2672

How to Edit Optical Lab Order Form Online for Free

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Step 1: Click on the "Get Form" button at the top of this page to access our tool.

Step 2: This editor will let you work with the majority of PDF documents in various ways. Modify it with your own text, correct what's already in the file, and place in a signature - all when you need it!

It will be simple to complete the pdf using out helpful tutorial! This is what you want to do:

1. The optical shop forms will require particular details to be inserted. Ensure that the subsequent fields are complete:

Filling out part 1 in Marietta

2. Right after finishing this part, head on to the next stage and enter all required details in these blanks - SPH, CYL, AXIS, DIST PD, NEAR, Seg Height, ADD, DECENTRATION, PRISM, BASE, THICKNESS, INSET, TOTAL, OUT, and SPECIFY.

INSET, PRISM, and ADD of Marietta

People generally make some errors while completing INSET in this part. Don't forget to double-check whatever you enter here.

3. In this step, take a look at TINT, SOLID, GRADIENT, BRIDGE, TEMPLE, FPD, LENS CIRC, MARK UP, N PICK COLOR STRENGTH, TREATMENTS, SPECIAL, GRY BRN PNK, ROS TAN BLU, G PGX PBX, and UV Protection. Each one of these are required to be filled in with highest accuracy.

Part number 3 for submitting Marietta

Step 3: Once you've glanced through the information in the file's blank fields, press "Done" to complete your FormsPal process. Go for a 7-day free trial account at FormsPal and gain instant access to optical shop forms - download, email, or edit inside your personal cabinet. FormsPal is devoted to the privacy of our users; we make certain that all personal information entered into our editor remains confidential.