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Get Univet Dental Loupes

LOUPES ORDER FORM Dental Surgical Protocol Order number Date / Customer Address/Street Number Postal Code Town County User s name Customization User s height Note The user has prescription glasses YES The user wears contact lenses NO if the user has prescription glasses please attach the copy of the prescription or fill the chart here below RIGHT EYE Sphere LEFT EYE Cylinder Axis LENS SPECTACLES Neutre distance Distance correction intermediate close-up Close-up correction ADDITION Model TTL Bifocal Declination angle F/U Type Galileian 1 meas. Magnification Working distance X Prismatic TOTAL INTERPUPILLARY DISTANCE INFINTE VIEWING WORKING DISTANCE VIEWING FRAMES FOR TTL Univet-01 TECHNE FRAMES FOR FLIP/UP EVO galileian White/red IRIS S Black Pink IRIS L Orange ASH S Grey/Grey AIRX prismatic Black/Red ASH L AIRX galileian Grey Headband prismatic White avalable for customized TTL until 31/12/2011 PICTURE NUMBER/NAME SALES AGENT SIGNATURE CUSTOMER SIGNATURE We point out that only a complete and proper making out of the form will enable us to start the production process and respect lead times. LOUPES ORDER FORM Dental Surgical Protocol Order number Date / Customer Address/Street Number Postal Code Town County User s name Customization User s height Note The user has prescription glasses YES The user wears contact lenses NO if the user has prescription glasses please attach the copy of the prescription or fill the chart here below RIGHT EYE Sphere LEFT EYE Cylinder Axis LENS SPECTACLES Neutre distance Distance correction intermediate close-up Close-up correction ADDITION Model TTL Bifocal Declination angle F/U Type Galileian 1 meas. Magnification Working distance X Prismatic TOTAL INTERPUPILLARY DISTANCE INFINTE VIEWING WORKING DISTANCE VIEWING FRAMES FOR TTL Univet-01 TECHNE FRAMES FOR FLIP/UP EVO galileian White/red IRIS S Black Pink IRIS L Orange ASH S Grey/Grey AIRX prismatic Black/Red ASH L AIRX galileian Grey Headband prismatic White avalable for customized TTL until 31/12/2011 PICTURE NUMBER/NAME SALES AGENT SIGNATURE CUSTOMER SIGNATURE We point out that only a complete and proper making out of the form will enable us to start the production process and respect lead times.

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  • Customization
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  • EVO
  • 2011
  • LOUPES
  • Bifocal
  • Prismatic
  • declination
  • Headband
  • Intermediate
  • magnification
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