Deerfield Billing

Billing

* Indicates required field

Patient Name *

First

Last

Date of Birth *

Select One *

Last 4 of Social Or VSP Auth *

Insurance *

Frame Brand *

A *

B (height) *

Bridge *

ED *

Contact lens Brand *

Number of boxes *

Frame Model Number *

R-SPH *

R-CYL *

R-Axis *

R-PD *

R-ADD *

R-Seg Height *

L-SPH *

L-CYL *

L-AXIS *

L-PD *

L-ADD *

L-Seg Height *

Material *

CR-39 Polycarbonate Mid index High Index

A/R *

Regular Premium Blue Blocker None

Tint *

Polorized Match Tint Transition Transition Extra Active No tint

Lens Type *

SV FT 28 Standard Progressive Preimum Progressive Digital Progressive

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