3139 Christy Way South Saginaw, MI. 48603 Phone 800-638-1171 FAX:800-806-1663 EMAIL:
[email protected] Bill To: 2830 Unified PL-114 CPL-115 Name Unified Brands Lisa Adams 888-994-7636 X6745
[email protected] ID # 4650 54th Street MAIP Pryor, OK 74361-4520
Order Date
Patient Information
Ship To:
Pryor Eye Clinic Danielle Wasserman 918-825-4427 1020 NE First Street Pryor, OK 74361
Phone # (
I-EOM-E D
430
)
Dispenser: To complete the Prescription Safety Glasses order form, please circle one or more items in each section below. Self Pay
Section 1 - Lens Material (Circle one material) Plastic Polycarbonate
00 - 21 1
Basic Impact Only-3.0 mm
High Impact - 2.0 mm
Self Pay
Section 6 - Frames (Circle Frame Style) Frame Group A - Hi-Tech Package Frame Group
Preferred Material
Honeywell/Titmus
SW06
FC706
BC101
BC115
Hudson Armourx
SL-4 7012
SL-5 7013
SL-6 7014
7702
BC116
Included
Duty to Warn: Polycarbonate is the most impact resistant material & recommended for all safety glasses.
Plastic
Section 2 - Lens Style (Circle one style) Single Vision Plastic or Poly Bifocals D28 Only Plastic or Poly Trifocals 7X28 Only Plastic or Poly Double Segment Plastic Sola Access (Computer Lens) Plastic or Poly Progressive-Standard Min.Seg.Ht.18 Plastic or Poly Progressive- Comfort Min.Seg.Ht.18 Plastic or Poly Progressive- Natural Min.Seg.Ht.18 Plastic or Poly Progressive- Novella Min.Seg.Ht.14 Plastic or Poly Progressive- Physio Min.Seg.Ht.17 Poly Styles are available in only those materials listed above.
$ $ $ $ $ $ $ $ $
Poly
35.00 20.00 75.00 75.00 75.00 NA
$ $ $
-
NA $ 20.00 $ $ 75.00 $ 75.00 $ 75.00 $ 125.00
Section 3 - Lens Options (Circle option) Multi-Focal Wider than Standard D35, 7X35, 8X35, Full Line (Executive)
$
12.00
1000,1001, 4001
Section 4 - Lens Coatings (Circle all required)
NOTES: Selection of items not on the order form, including frames other than those listed above, will delay order for a minimum of 5 days. Frames underlined are scheduled to be discontinued and may not be available.
Scratch Coat Both Sides CR-39 Plastic Only Premium Scratch Coat 1 Year Warranty - One time only replacement.
1004 $ 1015 $
5.00 25.00
Other Frame Lines Allowed include:
Anti-Reflective Coating Super Anti-Reflective Ultra-Violet Filter
4000 $ 4008 $ 1005 $
35.00 70.00 10.00
Eye Size Bridge Size Frame Color
$
42.00
1 Year Warranty - One time only replacement.
Anti-Fog
ANTI FOG
Section 7 - Frame Options (Circle option requested) Detachable Side Shields
REQUIRED !
51-59 2023-N $
Silicon Nose Pads Dispensing Fee
Shipping Fee
RX Prescription Information Sphere Cylinder Axis Prism
The employee is responsible for any amount in the self pay columns. This amount will be payroll deducted.
Base
$
EMPLOYEE GRAND TOTAL (For All Sections.)
Seg. Height for ALL multifocals Add Seg Height
Must have PD Distance PD
Vertex Pantoscopic Distance Tilt
Right OD Left OS Special Instructions:
Lenses Only
[ ]
RX Provider Signature:
RX Date:
Readers [ ]
Frame Only
[ ]
RX Provider Phone:
RX Expiration:
Near PD
Purchase Authorized By Signature
Employee Signature for Payroll Deduction
Date
Signature:
Title 3.51 - Unified Brands - Pryor 12/4/2014 4:42 PM
I-EOM-E
2.50
5001, 5002, 5003 Included 2035 $ 2060 Included
Eyeglasses Case
Progressive Lens (Non-Adapt) or Doctor Error Warranty: No Refunds. Hi-Tech Optical will remake the glasses in Single Vision, Bi-Focal or Tri-Focal at no charge or upgrade a progressive at employee cost (one time only) if notified within 60 days.
Included
Date:
Wrap Angle
December 4, 2014
PRESCRIPTION SAFETY EYEGLASS PROCEDURE Dear Employees, 1. Pick up your safety prescription order form and have it signed by your supervisor or manager. 2. If you do not have a current eye prescription, please call the provider for an eye exam appointment. ** Eye exams are responsibility of employee. 3. Take the Provider Letter, Order Form, and your prescription to the provider listed below. (Fill out top of form with name, ID#, phone, etc.) 4. Pick out frames. Provider will fill out the remainder of the order form and send it to Hi-Tech Optical. 5. Employees are financially responsible for any additional options chosen that are allowed within your program. The extra cost is available to be paid through employee payroll deductions. (Please see Order Form for allowed options.) 6. Once Hi-Tech has manufactured your glasses, they will send them back to the provider, where you will pick them up and get a professional fitting.
Provider Information: Pryor Eye Clinic 1020 NE First Street Pryor, OK 74361 (918) 825-4427
Hours: Monday – Thursday: 8:00 am to 5 pm (Closed from 12:00 pm to 1:00 pm for lunch) Friday: 8:00 am to 12:00 pm
Program Includes: •
•
Plastic or Polycarbonate Lens Material • Single Vision • Bifocals D-28 • Trifocals 7x28 • Progressive (Hi-Tech Choice) • Any Prescription Power • Any Prism Any Multifocal Prescription Add Power • Hi-Tech Package Frames • Detachable Side Shields • Eyeglass Case • Shipping (First Class Mail)
Unified Brands will provide employees with the above program inclusions at no cost to the employee. Employees are financially responsible for any additional options chosen that are allowed within your program. The extra cost is available to be paid through employee payroll deductions. (Please see Order Form for allowed options.)
Any questions please call Customer Service at Hi-Tech Optical: 1-800-638-1171 or Fax: 1-800-806-1663.
Prescription Safety Glass Procedure Dear Doctor, To be in compliance with State and Federal Laws, this employee is required to wear safety glasses. They selected you for the eye examination. Any fees incurred through examination, verification, or fitting will be a personal matter between you and your patient. We ask your cooperation in completely filling out the enclosed prescription form, including lens style, papillary distance, multifocal height and all frames information. We allow plastic or polycarbonate lens material. Please discuss this with our employee and select the material that suits your patient. 1.
Our supplier is Hi-Tech Optical, Inc..
2.
We only allow a frame selection from a select number of frames. Please see the order form.
3.
We allow Clear lenses.
4.
Scratch Coatings are advised on plastic lenses. Ultra Violet filtering is allowed if Doctor or employee’s job assignment required.
5.
All safety glasses will have clip-on side shields.
6.
Lenses SV, D-28 Bifocals, or 7 x 28 Trifocals and standard progressive (MIN HEIGHT 18) are authorized..
7.
Options outside of the standard program have additional charges which may be payroll deducted. IF YOU SHOULD NEED FURTHER INFORMATION ON THEIR PRODUCT LINE, YOU MAY PHONE: HI-TECH OPTICAL SAFETY DEPARTMENT 3139 Christy Way South Saginaw, MI 48603 (989) 799-9390 or (800) 638-1171
After you have finished your examination and completed the prescription form, please return it directly to the above address. In an effort to achieve complete accuracy in the filling of your patient’s prescription, Hi-Tech will return the glasses to you for inspection. After you are satisfied with the accuracy of the prescription, we ask you to notify your patient, so they may come to your office and professionally fitted. Thank you for your time. I have read and fully understand the above. ________________________ Employee Signature
_____________ Date
____________________ Printed Name
4650 54th Street MAIP, Pryor, OK 74361 1055 Mendell Davis Drive, Jackson, MS 39272 • 888.994.7636 • 888.864.7636 • unifiedbrands.net ADDITIONAL MANUFACTURING LOCATION: 525 SOUTH COLDWATER ROAD, WEIDMAN MI 48893 © 2009 Unified Brands. All Rights Reserved. Unified Brands is a wholly-owned subsidiary of Dover Corporation.
