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INTEGRAL
SERVICE
VISION &
HEARING

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If you can not come to our centers, or need a special glasses with Palomar filters to improve vision, contrast or eliminate the photophobia, we offer you the possibility of ordering a special glasses with Palomar filters by filling out the following questionnaire. Once all the data are valued, we will contact you.
      ORDER GLASSES WITH COP FILTERS
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Patient name   Prescriber

 
Phone:
E-mail:
Repeat E-mail:

Far
Near





Far and near ADDITION



 
AXIS
CYLINDER
SPHERE
   
 
 
RE


 
LE



     
BINOCULAR INTERPUPILAR DISTANCE (A) mm.
 
RE NASOPUPILAR DISTANCE (B) mm.
 
LE NASOPUPILAR DISTANCE (C) mm.
 
 
COP FILTERS


 
GLASSES DESCRIPTION
 
MODEL CALIBER COLOUR
 
COP GLASSES CHOOSED
OWN GLASSES SENT

 
Documents / Attachments

Attach file 1:

Attach file 2:

Attach file 3:

Attach file 4:

Remarks:


  



REQUEST CONDITIONS:
BY CARRYING OUT THE ORDER YOU ARE RESPONSABLE THAT THE PROVIDED DATA WILL BE REAL, ANY ERROR IN THEM AND CONSEQUENCES, WILL BE YOUR RESPONSIBILITY, NOT ADMITTING ANY CLAIM FOR THEM.
WE BEG YOU TO CHECK WITH THE MAXIMUM ATTENTION ALL THE INTRODUCED DATA TO AVOID ERRORS.

AS SOON AS POSSIBLE WE WILL KEEP IN TOUCH WITH YOU.
 

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