USE THIS FORM FOR ALL
SURFACED
LENS ORDERS
AND FTF CUT & FITS
TELEPHONE 011 440 7072
WHATSAPP 083 652 3539
Todays Date
04
/
04
/
2025
To: LENZXPRESS
Practice Name?
(abbreviation ok)
Your Name?
Your Reference
Where to send Confirmation email
(enter your email)
DELIVERY
Please deliver
Will collect
R LENS ORDER
REFRACTIVE INDEX
Please select
N/A
1.49
1.56
1.59 (POLYCARB)
1.61
1.67
1.74
Please select
R LENS TYPE
(not searchable on mobiles)
Rx R LENS
Plus
Minus
N/A
RIGHT Sphere
Please select
N/A
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
5.25
5.50
5.75
6.00
6.25
6.50
6.75
7.00
7.25
7.50
7.75
8.00
8.25
8.50
8.75
9.00
9.25
9.50
9.75
10.00
10.25
10.50
10.75
11.00
11.25
11.50
11.75
12.00
12.50
13.00
13.50
14.00
14.50
15.00
15.50
16.00
16.50
17.00
17.50
18.00
18.50
19.00
19.50
20.00
Please select
RIGHT Cylinder
N/A
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
-2.50
-2.75
-3.00
-3.25
-3.50
-3.75
-4.00
-4.25
-4.50
-4.75
-5.00
-5.25
-5.50
-5.75
-6.00
N/A
AXIS (degrees)
READING A D D
N/A
+0.50 (FF only)
+0.75 (FF only)
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25 (FF only)
+3.50 (FF only)
N/A
Quantity
RIGHT EYE Instructions (ARC, PRISM, TINTS etc)
L LENS ORDER
REFRACTIVE INDEX
Please select
N/A
1.49
1.56
1.59 (POLYCARB)
1.61
1.67
1.74
Please select
L
LENS TYPE
(not searchable on mobiles)
Rx L LENS
Plus
Minus
N/A
LEFT Sphere
Please select
N/A
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
3.75
4.00
4.25
4.50
4.75
5.00
5.25
5.50
5.75
6.00
6.25
6.50
6.75
7.00
7.25
7.50
7.75
8.00
8.25
8.50
8.75
9.00
9.25
9.50
9.75
10.00
10.25
10.50
10.75
11.00
11.25
11.50
11.75
12.00
12.50
13.00
13.50
14.00
14.50
15.00
15.50
16.00
16.50
17.00
17.50
18.00
18.50
19.00
19.50
20.00
Please select
LEFT Cylinder
N/A
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
-2.50
-2.75
-3.00
-3.25
-3.50
-3.75
-4.00
-4.25
-4.50
-4.75
-5.00
-5.25
-5.50
-5.75
-6.00
N/A
AXIS (degrees)
READING A D D
N/A
+0.50 (FF only)
+0.75 (FF only)
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25 (FF only)
+3.50 (FF only)
N/A
Quantity
LEFT EYE
Instructions
(ARC, PRISM, TINTS etc)
FRAME TO FOLLOW
If Yes remit a copy of
this order with frame
Yes
No
FTF DETAILS
CUT & FIT PD
CUT & FIT SEG HT
CUT & FIT
Instructions
(if any)
ORDER NOW
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