Patient/Reference	*
	Both Eyes Right Only Left Only

	Material	Colour	Coating	SPH	CYL	Size	Quantity	Price
Right	Select	Select	Select	Select	Select
Left	Select	Select	Select	Select	Select
							Total

Confirm Order

Patient/Reference:
Right:
Left:
			Total:

Note: 20% Restocking fee will be charged on all stock lenses returns.