Phone and Fax Orders

Print out this page and fill in the required information. For phone orders call 1-800-634-6786 give us the information, and keep the form for your record. For fax orders, fax the completed form to 1-800-677-1892 and keep your copy. TRAY Great Basin optical laboratories 3175 W. Ali Baba Lane #803 Las Vegas, NV 89118 800-634-6786 · FAX 702-895-9231 Free FAX 800-677-1892   DATE   PATIENT   Uncut SPH.   CYL. AXIS PRISM BASE DIST PD. NEAR PD. DIST R               L               EYE SIZE/A DBL ADD HEIGHT OC HGT BASE CURVE     ADD R         ED B L             LENS POLARIZED SV BIF TRI PROG LENS COLOR PLASTIC HI INDEX POLY GLASS   FRAME ENCL TO COME SUPPLY FRAME NAME METAL ZYL NYLON SPECIAL INST. FRAME   LENSES   EDGING   OVERSIZE   HIGH POWER   A/R   TINTING   Your Business Name:     Your Name: TAX     SHIPPING   PHONE NO. TOTAL