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Get GA Avesis Essilor / Select Optical Order Form

DGE CTR. R CR - 39 THICKNESS L DIST PD NEAR PD ADD CYLINDER AXIS SEG HT. INSET TOTAL OC DEC. THICKNESS R Medically Necessary Polycarbonate L SPHERE OUT UP PRISM DOWN EDGE CTR. R L DIST PD NEAR PD ADD CYLINDER AXIS SEG HT. INSET TOTAL OC DEC. THICKNESS R L SPHERE Patient Requested Polycarbonate PRISM IN PRISM IN OUT UP PRISM DOWN EDGE CTR. R L DIST PD NEAR PD ADD SEG HT. INSET TOTAL OC R L EDGE FOR ZYL GROOV.

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