Order Form

Customer Information


Customer Number:
Phone Number:
Practice Name:
Email Address:
Contact Person:
Patient Name:
Zip Code:
Check here if you are a new customer.  Your Conforma representative will call you to establish your customer account.

Lens Information


OD (Right Lens)OS (Left Lens)
Lens Type:
Material:
Color:
Base Curve:
Second Radius:
Third Radius:
Bevel Radius:
Power:
Back Vertex:
Front Vertex:
Lens Size:
Optic Zone:
Center Thickness:
Dot:
Lenticular:
   Size:    Size:
Lenticular MC:
   Size:    Size:
VFL Super Add VFL Super Add
F.O.Z.
Add:

Special Instructions


Warranted Non-Warranted
New Fit WA Exchange - Invoice #
Special Instructions:
(clear all fields) Submit Order

Confirmation


You should receive a confirmation e-mail within 24 hours of placing your order. If you do not receive a confirmation e-mail from us, please contact Customer Service at 1-800-426-1700 or info@conforma.com to verify that we received your order.

If you receive a confirmation e-mail from us, then no further action on your part is needed.