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Get Atlanta Eye Custom Optical Laboratories Form

Bout the option of impact resistant polycarbonate lenses. **Medicaid ID # (required or write N/A) JOB TYPE PATIENT LAST NAME Frame Only Lenses Only New Job Optician initial here: PATIENT FIRST NAME Contact Name and Phone Number SEG TYPE (circle) MATERIAL (circle) S/V - Single Vision Plastic FlatTop28 SPECIAL BC TOTAL PAID $ SPH CYL Progressive (requires Monocular PD) Polycarb (-5.25/+4.00) TYPE Hi Index (1.67) AXIS DIST PD NEAR Add Transitions Brown Grey Seg Height ADD .

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