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SERVICE
INTEGRAL
VISION ET
AUDITION

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If you cannot be attended in our centres, or you require glasses with Palomar´s prisms for a patient with right homonymous hemianopia, we offer you the possibility to order it, filling out the following questionnaire. Once we valued all the data, we will contact you.
ORDER EYEGLASSES WITH PALOMAR'S PRISMS©
RIGHT HOMONYMOUS HEMIANOPIA(RHH)
logo_COP-2_300_trans-gris   

pedido_HHD2

Patient name   Prescriber

 
Phone:
E-mail:
Repeat E-mail:

Far
Near

 
AXIS
CYLINDER
SPHERE
   
 
 
RE


 
LE



     
INTER-PUPILLARY BINOCULAR DISTANCE (A) mm.
 
NASO-PUPILLARY DISTANCE RE (B) mm.
 
NASO-PUPILLARY DISTANCE LE (C) mm.
 
 
DATA ASSEMBLY
 
I want the assembly data to be calculated by CENTROS PALOMAR
depending on the information provided

 POWER PRISMS RE   BT

 POWER PRISMS LE    BN

 INITIAL VERTEX PRISM RE (D)          

 INITIAL VERTEX PRISM LE (E)           

 
EYEGLASSES DESCRIPTION
 
MODEL CALIBER COLOR
 
It eyeglasses by COP
Sent own eyeglasses

 
Documents / attachments

Attach File 1:

Attach File 2:

Attach File 3:

Attach File 4:

Remarks:


  



CONDITIONS OF ORDER:
ON HAVING REALIZED THE ORDER YOU HAVE TO BE RESPONSIBLE THAT THE CONTRIBUTED INFORMATION WILL BE REAL, ANY MISTAKE IN THEM AND ITS CONSEQUENCES WILL BE YOUR RESPONSIBILITY, NOT ADMITTING ANY CLAIM FOR IT.
WE REQUEST YOU TO CHECK WITH THE MAXIMUM ATTENTION ALL THE INFORMATION INTRODUCED IN ORDER TO AVOID ANY MISTAKES.

SOON WE WILL CONTACT YOU.
 

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