Place Order

Use the handy form below to submit your orders to us. Fill out any information about your order, you do not need to fill out every empty space.

Click “Submit” and we will process it immediately.

For more help call us at 800-488-2020 or email us at info@visionarylens.com

Account Number

Practice Name

Patient Name

Warranty

Ship to Location

Design (R)

Design (L)

Material (R)

Material (L)

Color (R)

Color (L)

Base Curve (R)

Base Curve (L)

Power (R)

Power (L)

Diameter (R)

Diameter (L)

Optic Zone Diameter (R)

Optic Zone Diameter (L)

Center Thickness (R)

Center Thickness (L)

Second Curve Radius (R)

Second Curve Radius (L)

Second Curve Width (R)

Second Curve Width (L)

Third Curve Radius (R)

Third Curve Radius (L)

Third Curve Width (R)

Third Curve Width (L)

Fourth Curve Radius (R)

Fourth Curve Radius (L)

Fourth Curve Width (R)

Fourth Curve Width (L)

checkbox

Dot OD

Dot OS

Plasma Treatment

HydraPEG Coating

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