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