ORDER FORM

CHRISTINA XARCHOULAKOU
CONTACT: ________________________ PO# _____________________
GERASIMOS LIVIR-RALLATOS
CUSTOMER ________________________________ If different than Ship to address
SHIP TO: __________________________________ BILL TO: _________________________________
6 KILELER STR, HILIOUPOLIS
__________________________________________ ________________________________________
__________________________________________ ________________________________________
ATHENS
CITY_______________ST 16346=+
________ZIP _________ CITY______________ST _______ ZIP _________

CC: ______________________________________
+302109957401
TELEPHONE _______________________________ EXP: ________________________ V, MC, AMEX

3M Press-On™ Optics
PRISMS ASPHERIC - PLUS ASPHERIC - MINUS ASPHERIC - D-SEGS

Item# Qty Diopter Item# Qty Power Item# Qty Power Item# Qty Power

1010 ______ 1.0 U 2005 ______ + .5 4010 ______ -1.0 3010 ______ 1.0
1020 ______ 2.0 U 2010 ______ +1.0 4020 ______ -2.0 3015 ______ 1.5
1030 ______ 3.0 U 2015 ______ +1.5 4030 ______ -3.0 3020 ______ 2.0
1040 ______ 4.0 U 2020 ______ +2.0 4040 ______ -4.0 3025 ______ 2.5
1050 ______ 5.0 U 2025 ______ +2.5 4050 ______ -5.0 3030 ______ 3.0
1060 ______ 6.0 U 2030 ______ +3.0 4060 ______ -6.0 3040 ______ 4.0
1070 ______ 7.0 U 2035 ______ +3.5 4070 ______ -7.0 3050 ______ 5.0
1080 ______ 8.0 U 2040 ______ +4.0 4080 ______ -8.0 3060 ______ 6.0
1090 ______ 9.0 U 2050 ______ +5.0 4090 ______ -9.0
1100 _____ 10.0 U 2060 ______ +6.0 4100 ______ -10.0
1120 _____ 12.0 U 2070 ______ +7.0 4110 ______ -11.0
1150 _____ 15.0 U 2080 ______ +8.0 4120 ______ -12.0
1200 _____ 20.0 U 2100 ______ +10.0 4130 ______ -13.0
1250 _____ 25.0 U 2120 ______ +12.0 4140 ______ -14.0
1300 _____ 30.0 U 2140 ______ +14.0
1350 _____ 35.0 U 2160 ______ +16.0
1400 _____ 40.0 U FRESNEL PRISM TRIAL SETS
TS 4000 _______With Handle
TS 5000 _______With Handle
1900 ______ FRESNEL OPTIC CLEANING KIT
TS 4000 _______Without Handle
TS 5000 _______Without Handle

6824 Washington Ave. S. 1-800-544-4760 US & Canada email : info@fresnelprism.com

Eden Prairie, MN 55344 1-952-496-0432 Direct www.fresnel-prism.com
1-952-403-7900 Fax `ˆÌi`Ê܈̅Ê̅iÊ`i“œÊÛiÀȜ˜ÊœvÊ
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ORDER FORM

BANGERTER OCCLUSION FOILS OTHER PRODUCTS

Item Qty Visual Acuity Item Qty

6000 Foil 00 ______ None 7001 LANG STEROTEST #1 ______
60LP Foil LP ______ None, Light Perception 7002 LANG STEROTEST #2 2
______
60<1 Foil <0.1 ______ ~20/300 700C LANG FIXATION CUBE 2
______
6010 Foil 0.1 ______ ~20/200 700S LANG FIXATION STICK ______
6020 Foil 0.2 ______ ~20/100 700S-C LANG FIXATION STICK COVER ______
6030 Foil 0.3 ______ ~20/70 7101P 2
FIXATION STICK WITH PUPIL GAUGE _______
6040 Foil 0.4 ______ ~20/50 7102R 2
FIXATION STICK WITH CORNEAL RULE_______
6060 Foil 0.6 ______ ~20/30 6400 HELVESTON COLOR ACUITY CHART ______
6080 Foil 0.8 ______ ~20/25 66001 OCCLUDING FIXATION PADDLE 2
______
6100 Foil 1.0 ______ ~20/20 6600 SPIELMANN OCCLUSION PADDLE 2
______
6300 FOIL BAR ______ 6700 MIN OCCLUSION LENS ______
6702 TRANSPARENT OCCL. PADDLE 2
______

5322R ADULT TRIAL FRAME SET ______ 6650 APPLE PATTY PATCHES BOOK ______

5317R PEDIATRIC TRIAL FRAME SET 2

______ 6651 ALL CHILDREN HAVE DIFFERENT EYES BOOK ______
6201G i-TEST PORTABLE PHOROPTER _______ 8001 NIGHT GLARE GLASSES ______
*JULBO CHILDREN’S SUNGLASSES
“EP” HEMIANOPIC AIDS – CONTACT OFFICE FOR DETAILS
CONTACT OFFICE DIRECTLY FOR SIZES AND COLORS
12122 OCCLUDER & MADDOX ROD 2
______ 5110 ROLL -TEMP. SCREENING PATCHES 4
______
12126 COMBO OCCLUDER ______ 5110D DISPENSER FOR PATCH ROLL ______

5200 PERFECT PATCH Girl Print ______ Boy Print ______

MYI EYE PATCHES USE SEPARATE ORDER FORM

6824 Washington Ave. S. 1-800-544-4760 US & Canada email : info@fresnelprism.com

Eden Prairie, MN 55344 1-952-496-0432 Direct www.fresnel-prism.com
1-952-403-7900 Fax `ˆÌi`Ê܈̅Ê̅iÊ`i“œÊÛiÀȜ˜ÊœvÊ
˜vˆÝÊ*ÀœÊ*Ê `ˆÌœÀÊ

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