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    Order Lense for doctor in Vietname, Laos, Thailand, Cambodia only:

    Facility Name (required) Example: Benh Vien Mat
    Address (required) Example: 25 Dong Nai, P.4, Q.10, SaiGon, Vietnam
    Phone (required) Example: 0995180730
    Email (required) info@libertycommercialmd.com

    Patient name (required) Example: Liberty Nguyen
    Patient age (required) Example: 17

    MP/ OD
    PWR Example: -5.5 (-1.75 x 0)
    K1 (required) Example: 44.25/ 7.65
    K2 (required) Example: 46.5/ 7.26
    HVID (required) Example: 11.3

    MT/OS
    PWR (required) Example: -6 (-3 x 0)
    K1 (required) Example: 44.25/ 7.61
    K2 (required) Example: 46/ 7.34
    HVID (required) Example: 11.3

    Order Set (required) Example: Full
    MP/OS (required) Example: HC 12
    MT/OS (required) Example: HE 12
    NOTE (required) Example: Please delivery the lenses ASAP. Thank you.
    Date of order (required) Example: 1/1/2014