Your Order Form

Home » For Prescribers » Online Order Form

Your Online Bioptic Order Form
-For EyeCare Professionals ONLY-

Patients CANNOT order Ocutech products directly.
Thus you must be an eyecare professional and have an account established with Ocutech before you can place an order.

NOTE: Form data is transmitted to the server over an encrypted, SSL secured connection. You will receive confirmation of your order by return email.

"*" indicates required fields

1. Business Information

Autofill business information?

Date*

MM slash DD slash YYYY

Account Name*

Action Requested*

Estimate Only

Place Order

Prescriber's Name*

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.

Street Address

Address Line 2

City

State Province/Region

Zip Code/Postal Code

Country

Phone

Fax

Office Contact*

Email*

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

Save business information for next time?

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2. Patient Information

Patient Last Name*

Patient First Initial

P.O. Number

(optional)

Patient Age

(optional)

Gender

(optional)

Patient Diagnosis

(optional)

Activity goal(s) with Device

(optional)

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3. Product Information

Which product are you ordering?*

"Carrier Lenses or Frame Only" and "SideSight" recently added to dropdown options.

Which product will be used with the carrier lenses?*

SightScope TS for which Eye?*

Binocular

SightScope TS Power*

1.7x

2.2x

0.5x (FE)

Type of order*

Frame-Mounted System

Patient Clip System

Demonstrator Clip System

SS2 TS for which Eye?*

Binocular

SightScope TS Power*

1.7x

2.2x

Type of order*

Frame-Mounted System

SSNV TS for which Eye?*

Binocular

SightScope NearView*

+1.5

(Add Power)

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Placeholder

We recommend the Sleek frame to use with the SightScope Nearview

Falcon TS for which Eye?*

TS Power*

5.5x

TS case color:*

Black

Silver

Exact PD for telescope:*

for position of ts eyepiece in mm

Falcon Eyepiece Correction?*

Yes Eyepiece Correction

No Eyepiece Correction

Specify power:

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E TS for which Eye?*

TS Power*

TS case color :*

Black

Silver

Blue

Red

Pink

(no extra charge for colors)

Exact PD for telescope:*

for position of ts eyepiece in mm

Explorer Eyepiece Correction Needed?*

Yes Eyepiece Correction

No Eyepiece Correction

Specify power:

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K TS for which Eye?*

TS Power*

TS case color:*

Black

Exact PD for telescope:*

for position of ts eyepiece in mm

K Eyepiece Correction Needed?*

Yes Eyepiece Correction

No Eyepiece Correction

Specify power:

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Sport TS for which Eye?*

TS Power*

TS case color:*

Black (standard)

Silver (standard)

Blue (custom)

Red (custom)

Pink (custom)

Green (custom)

Other

Exact PD for telescope:*

for position of ts eyepiece in mm

Sport Eyepiece Correction Needed?*

Yes Eyepiece Correction

No Eyepiece Correction

Specify power:

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Mini Type of order*

Patient System

Demo Clip

Trial Ring (used with Trial Frame)

Un-mounted telescopes

M TS for which Eye?*

Binocular

Is TS for distance or near?*

Distance

Near

TS case color:*

Black

Silver

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)

Trial Ring TS Placement*

Center Position

Bioptic Position

Enter Quantity

Eyepiece Correction Needed?*

Yes OD Eyepiece Correction

Yes OS Eyepiece Correction

Yes OU Eyepiece Correction

No Eyepiece Correction

Specify OD Power:

Specify OS Power:

Order:*

Field Viewer (-4D) (.25x)

Handheld Image Minifier (0.5x)

Unmounted Image Minifier (0.5x)

Spectacle Mounted Image Minifier (0.5x)

Select Quantity

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TS for which eye?*

Binocular

Position of IM in frame

mm below top of frame
(minimum 13mm)

OD (mm):*

Exact PD for eyepiece(s) (mm)

OS (mm):*

Exact PD for eyepiece(s) (mm)

Select Desired Version

TS for which eye?*

Binocular

Select Reveal Power*

2.2x Galilean Telescope (TS)

O.5x Field Expander (FE)

Pt Clip Reveal Power

O.5x Field Expander (FE)

TS case color:*

Black

Silver

TS case color:*

Silver only

MM below top of lens

(Std 10mm)

Degrees upward angle

(Std 10 degrees)

OD (mm)*

Exact PD for eyepiece(s)

OS (mm)*

Exact PD for eyepiece(s)

Select Quantity

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Reveal Frame

Prescriber provided

Ocutech provided
(specify below)

Prescriber Provided: Specify brand, name, size, color

SideSight Type Of Order

Patient Order

Stock Order

Enter Quantity

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TS for Which Eye?*

Exact PD for telescope:*

To cut slot in carrier lens for TS eyepiece (in mm)

Mini TS for Which Eye?*

Exact OD PD for telescope:*

To cut slot in carrier lens for TS eyepiece (in mm)

Exact OS PD for telescope:*

To cut slot in carrier lens for TS eyepiece (in mm)

Current Eyepiece Correction?*

Yes Eyepiece Correction

No Eyepiece Correction

Does current telescope have an Eyepiece Correction?
(It determines diameter of the slot cut into carrier lens)

NEW Eyepiece Correction on TS?

Yes Eyepiece Correction

No Eyepiece Correction

Do you need to update the lens prescription in the Eyepiece Correction?

Specify power of NEW Eyepiece Correction(s):

4. Carrier Lenses

Provide carrier lenses*

Yes

Lens Type

Current Progressive usually being used: Hoya Accord

Lens Material

If you are placing a Carrier Lenses ONLY order, please make sure to fill in the frame style and size below.

Lens Type Material:*

Trivex/Phoenix

OD:

Prism

ADD

Distance PD: OD (mm)

OS:

Prism

ADD

Distance PD: OS (mm)

Near PD: OD (mm)

Near PD: OS (mm)

Seg. height

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Lens Extras

Photochromic Lenses

Anti-reflective Coating

Scratch Coating

Solid Tint

Gradient Tint

Roll & Polish

High Luster Polish

Current ARC usually being used: Hoya HiVision ViewProtect

Lens Special instructions

(tint color, transition color, etc.)

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5. Frame

Ordering an Ocutech Frame?*

Yes

Carrier Lenses ONLY

Ordering an Ocutech Frame?*

Use Patient's Frame (Sending Frame In)

Do Lenses Only (NOT sending Frame In)

Supply New Frame

Select Frame Style*

Ocutech Unisex

Ocutech K Style

Ocutech Sleek

What size do you need?

47/18/140

49/18/140

51/18/140

53/18/140

55/18/145

For Ocutech Unisex Frame

What color would you like?

Gold (49 & 51 only)

Bronze

Silver

For Ocutech Unisex Frame

What size do you need?

48/18/140

51/18/140

53/18/140

55/18/145

57/18/145

For Ocutech K Style Frame

What color would you like?

Gold (not in 48)

Bronze

Silver

For Ocutech K Style Frame

Choose frame size:

50/18/140

53/18/145

For Ocutech Sleek Frame

Choose frame color:

Silver

Gun Metal

For Ocutech Sleek Frame

Frame Special Instructions

frame/temple length/cable temple/sideshield requests

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6. Accessories

Patient Case

Yes

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

Request Sunfilters

Yes

Slip-Behind Sun Filters

Gray

Brown

Blue Blocker

Yellow

Set of 4 (Gry, Brn, BB, Ylw)

Red (For Achromatopsia)

Magenta (For Achromatopsia)

(for Ocutech frames only)

Sun Filter

Covers eyepiece

Does NOT cover eyepiece

SS Filter Cap(s)

Yes (specify color)

Filter Cap

Yes (specify color)

Color

Quantity

SS Reading Cap(s)

Yes (specify power)

Reading Cap

Yes (specify color)

Power

Quantity

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7: Special Instructions

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8. Submit Order

**By submitting your order you confirm that all information is correct and that you agree to Ocutech's terms of sale.**
Once submitted, you will receive a confirmation email with a printable PDF attachment of the order/estimate for your records.

I would like to place another order after submission.*

YES (I would like to place another order)

NO (I am finished with Online Ordering)

This field is for validation purposes and should be left unchanged.

Your Order Form

Your Online Bioptic Order Form -For EyeCare Professionals ONLY-

1. Business Information

2. Patient Information

3. Product Information

4. Carrier Lenses

5. Frame

6. Accessories

7: Special Instructions

8. Submit Order

Your Online Bioptic Order Form
-For EyeCare Professionals ONLY-