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Consultation Request

Please provide the following information to the SpecialEyes consultation team to re-order trial lenses for your patient. Or, you may call us at 866.822.2020. For initial trial orders, please use the SpecialEyes Arc Length Calculator.
Contact Name
Email
Account Number
Patient Name
Contact Lens Fit
OD
Current Contact Lens Rx
Centered
Yes
No
Movement
Limbal Coverage
Rotation
deg
CW
CCW
Stable
Unstable
OS
Current Contact Lens Rx
Centered
Yes
No
Movement
Limbal Coverage
Rotation
deg
CW
CCW
Stable
Unstable
Vision
VA with Contact lenses
OD
20/ @ Distance
20/ @ Near
OS
20/ @ Distance
20/ @ Near
OU
20/ @ Distance
20/ @ Near
Distance Over-Refraction
OD
20/
OS
20/
Near Over-Refraction
OD
20/
OS
20/
Comments/Chief Complaint
By submitting this form you consent to receiving information from us related to this request. We respect your privacy and the protection of your personal data. You can learn how we handle information we collect by reading our privacy policy