master order forms

You must have an account established with Ocutech prior to placing your order.

Contact Ocutech at (1-800) 326-6460 or (919) 967-6460 or email customer service Customer Service to establish your account.

If you would like your business account information to be inserted for you, please log in. If the information inserted is incorrect, please contact us so we can update your account. Once logged in, you can click the VIEW PROFILE link in the header to view or edit your profile directly. It is not necessary for you to log in to place an order.

NOTE: Form data is transmitted to the server over an encrypted, SSL secured connection.

"*" indicates required fields

1. Business Information

Date*

Action Requested*

Estimate Only

Place Order

We will send a quote by email (Please allow 24 hours during weekdays). In order for us to process your order, you MUST send reply email stating that the estimate is acceptable and that you would like to proceed with the order.

Account Name*

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Prescriber's Name

Office Contact*

Phone*

Fax

Email*

2. Patient Information

Patient Last Name*

Patient First Initial*

P.O. Number (optional)

Patient Age (optional)

Male or Female? (optional)

Male

Female

Patient Diagnosis (optional)

Activity goal(s) for use of the device (optional)

3. Product Information

Which product are you ordering?*

Order:*

Field Viewer (-4D (.25x) (Provided w/ neck strap & pouch)

Handheld IM (Provided w/ neck strap, pouch & adjustment tools)

Unmounted IM (includes adjustment tools)

Spectacle Mounted IM (Complete options below, includes adjustment tools)

Telescope for which Eye?*

Binocular

PD (mm) OD:*

PD (mm) OS:*

Position of IM in frame: mm below top of frame (minimum 13mm)

Check desired version*

2.2x Galilean Telescope (TS) - Includes both straight and 7 degree tilted self adhesive flanges

O.5x Field Expander (FE) - Includes both straight and 7 degree titled self adhesive flanges

Instamount Demonstrator Clip - Accepts either TS or FE for testing purposes

Replacement 7 degree flange - 7 degree tilted Instamount self-adhesive mounting flange (set of 4)

Replacement straight flange - Straight Instamount self-adhesive mounting flange (set of 4)

Instamount mounted on Magnetic Clip Frame

Check desired Reveal version*

2.2x Galilean Telescope (TS)

O.5x Field Expander (FE)

Reveal Demonstrator Clip

Reveal Demonstrator Clip- accepts either TS or FE

Chasis color:*

Black

Silver

Type of order:

Patient System

Un-mounted telescopes

Type of order:

Un-mounted telescopes

Patient System

Select Quantity

Reveal Telescope for which Eye?*

Binocular

OD (mm)*

Exact PD for eyepiece(s)

OS (mm)*

Exact PD for eyepiece(s)

Telescope for which Eye?*

Binocular

SightScope NearView Version Number (Add Power)*

+1.5

Telescope for which eye(s)?*

Product*

2.2x TS

0.5x FE

Reveal Product*

2.2x TS

0.5x FE

Frame

Prescriber provided

Ocutech provided (specify below)

Reveal Frame

Prescriber provided

Ocutech provided (specify below)

Specify brand, name, size, color

Type of order*

Frame-Mounted System

Patient Clip System

Demonstrator Clip System

Type of order*

Frame-Mounted System

Patient Clip System

Specify brand, name, size, color

Telescope for which Eye?*

Binocular

SightScope Telescope Power*

1.7x

2.2x

0.5x (FE)

SightScope Telescope Power*

1.7x

2.2x

Telescope for which Eye?*

Telescope Power*

Telescope Position:

Style A: Standard (above the frame)

Style B: Bottom mounting

Exact PD for position of telescope eyepiece (mm):*

Please specify a quantity:

Chasis color:*

Black

Silver

Telescope for which eye?*

Binocular

Is this for distance or near telescopes?*

Distance

Near

OD (mm)*

Exact PD for eyepiece(s)

OS (mm)*

Exact PD for eyepiece(s)

MM below top of lens (Std 10mm):*

Degrees upward angle (Std 10 degrees):*

MM above bottom of lens (Std 15mm)

Degrees downward angle (Std 12 degrees)

Near working distance for binocular prescriptions:

Specify inches, cm

Telescope Power*

5.5x

Telescope Power*

Exact PD for position of telescope eyepiece (mm):*

Telescope case color:*

Black (standard)

Silver (standard)

Blue (custom)

Red (custom)

Pink (custom)

Green (custom)

Other

Telescope case color:*

Black

Silver

Do you need telescope eyepiece correction?

Yes

Specify power:

Telescope case color (no extra charge for colors):*

4. Accessories

Request Sunfilters

Yes

Slip-Behind Sun Filters (for Ocutech frames only)

Gray

Brown

Blue Blocker

Yellow

Set of Four (Grey, Brown, Blue Blocker, Yellow)

Red (For Achromatopsia)

Patient Case

(Cleaning cloth and neck strap are included with each system order)

Yes

Specify eyepiece aperture

Filter covers eyepiece

Eyepiece not covered by filter

Filter cap:

Yes (specify color)

Filter cap:

Yes (specify color)

Color

Reading Cap

Yes (specify power)

Reading Cap

Yes (specify power)

Power

For which eye(s)

Both

5. Carrier Lenses

Provide carrier lenses*

Yes

Lens Type*

e.g. single vision, multifocal, etc. If multifocal, please specify lens style (i.e.: FT28, Round, etc.)

Lens Type- Single vision distance correction recommended for SightScope NearView*

e.g. single vision, multifocal, etc

OD:

ADD

OS:

ADD

Distance PD: OD (mm)*

Distance PD: OS (mm)*

Near PD: OD (mm)

Near PD: OS (mm)

Lens Type Material:*

Seg. height

Special instructions (tint, coatings, etc.)

6. Frame

Would you like us to provide a frame?*

Yes

Choose Frame Style

Ocutech Sleek (we only recommend Sleek frame for this product)

Which type of frame would you like?*

Ocutech Unisex

Ocutech K Style

Ocutech Sleek

Pediatric

What size do you need?

For Ocutech Unisex Frame

49/18/140

51/18/140

53/18/140

55/18/140 (Bronze color only)

What color would you like?

For Ocutech Unisex Frame

Gold

Bronze

Silver

What color would you like?

For Ocutech Unisex Frame

Bronze

Silver

What size do you need?

For Ocutech K Style Frame

51/18/140

53/18/140

55/18/140

57/18/140

What color would you like?

For Ocutech K Style Frame

Gold

Bronze

Silver

Choose frame size:

50/18/140

53/18/140

Choose frame size:

50/18/140

53/18/140

Choose frame color:

Silver

Gun Metal

Choose frame color:

Silver

Gun Metal

What size do you need?

For Ocutech Pediatric Frame

K-Style 48/18/140

Unisex 47/18/140

What color would you like?

For Ocutech Pediatric Frame

Silver

Bronze

Which VES-II Frame would you like?

Pediatric and Adult Frames

Unisex

VES-II Telescope Systems can only be ordered with VES-II frames.

What size do you need?

46/22/135 (Pediatric)

50/24/140

54/24/150

What color would you like?

Crystal

Gray

Demi Amber

Tan (Adult sizes only)

What size do you need?

48/22/140

What color would you like?

Crystal

Gray

Demi Blonde

Special frame/temple length/cable temple/sideshield requests

7: Special Instructions

8. Submit Order

Billing*

Bill my account

Pay with credit card on file

Will wire funds (International orders require pre-payment)

We will call Ocutech with payment Information

Shipping*

In US: UPS Domestic Ground

In US: UPS 2nd Day

In US: UPS Overnight

International: DHL

**By submitting your order you confirm that all information is correct and that you agree to Ocutech's terms of sale.**

I would like to place another order after submission.*

YES (I would like to place another order)

NO (I am finished with Online Ordering)

master order forms

1. Business Information

2. Patient Information

3. Product Information

4. Accessories

5. Carrier Lenses

6. Frame

7: Special Instructions

8. Submit Order

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