Order Form Note: PolyVue does not sell products directly to patients. Please contact your eye care professional. Account # * Contact Name * First Name Last Name Phone * (###) ### #### Email * First Name Last Name Patient Name First Name Last Name Right Eye (OD) HDX2 Progressives_Monthly Multifocal (Effective Add +1.25 to +2.50) HD2 Aspherics_Monthly Single-Vision (Effective Add up to +1.00) HD Dailies_Daily Single-Vision (Effective Add up to +1.00) HD Pro Color_Monthly Colored Contacts HD High Definition_Quarterly Single-Vision (Effective Add up to +1.00) HDX Progressive_Quarterly Multifocal (Effective Add +1.25 to +2.50) HDX-T Progressive_Quarterly Mutifocal Toric Power / Sphere (For HD Pro Color only) +4.00 to -6.00 (Amethyst: 0.00 to –4.00) Choose One: Box Trial Quantity Left Eye (OS) HDX2 Progressives_Monthly Multifocal (Effective Add +1.25 to +2.50) HD2 Aspherics_Monthly Single-Vision (Effective Add up to +1.00) HD Dailies_Daily Single-Vision (Effective Add up to +1.00) HD Pro Color_Monthly Colored Contacts HD High Definition_Quarterly Single-Vision (Effective Add up to +1.00) HDX Progressive_Quarterly Multifocal (Effective Add +1.25 to +2.50) HDX-T Progressive_Quarterly Mutifocal Toric Power / Sphere (For HD Pro Color only) +4.00 to -6.00 (Amethyst: 0.00 to –4.00) Choose One: Box Trial Quantity Stock Replenishment Note: HD Dailies are supplied in 5-strip units. Additional Message
