If you do not currently have any VM envelopes, please print out this form and enclose it with your lenses. We will contact you with a control number for tracking purposes as soon as it is received. Please retain a copy of this form for your records.
| Company: | ___________________________________ |
| Address: | ___________________________________ |
| ____________________ Zip:___________ |
| Phone #: | ___________________________________ |
| Tray/Patient: | ___________________________________ |
| Date Sent: | ___________________________________ |
Prescription
|
| Rx | Sph | Cyl | Axis | Add | Seg |
| R | | | | | |
| L | | | | | |
__ Defects OK to Cote __ Any Defects Return Uncoated __Old Lenses __ 1/2 Pair
Return by: __ NDA __ 2nd Day __ Ground __ CalOver __USPS __ Courier Ski Cote (Similar to Vaurnet) |
| Amber Base | Rose Base | With A/R |
| Gold Mirror | Blue Mirror | Silver Mirror |
Edge Cote |
| Standard Color: _____________________ |
| Custom Color - Frame/Sample enclosed |
Anti-Reflective Coating: __ Both sides __ Backside Only
Quartz Scratch Coating : __ One Side __ Two Sides
| Plastic Mirrors | Flash __ | Light __ | Dark__ |
| Solid | Silver* | Multi: | Pastel: |
| Single Gradient | Gold* | Red | Pink |
| Double Gradient | Black | Green | Blue |
| Blue* | Yellow | Green |
| | Violet | |
Tint/Coating Type
| Grey* | 10 | 30 | | Med | Drk. | XDrk |
| Brown* | 10 | 25 | 55 | 75 | | |
| Green | 25 | 70 | | Yellow | 10 | 30 |
| Blue | 10 | 50 | | Rose | 10 | 30 |
| ___ Strip Only | ___ Strip & Cote |
Remarks & Special Instructions:
|
*Indicates the color is available as a gradient