SpecialEyes Multifocal Simulator
SpecialEyes Arc Length  and Over-Refraction Calculators
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Open an Account

To Design and Prescribe Custom Soft Contact Lenses

If you are an eye-care provider interested in opening a new account with SpecialEyes,
please complete and submit the form below. Alternately, you may call us at
866-404-1060
to create an account.

Practice/Business Name
OD
MD
LDO
Main Doctor or Licensed
Dispensing Optician Name
How many doctors or contact-
lens fitters are in the practice(s)?
OD
MD
Please list additional doctor’s
names (if applicable):
OD
MD
OD
MD
OD
MD
OD
MD
Contact Lens Technician
Billing Address
City \ State \ Zip
Shipping Address
City \ State \ Zip
Phone
Fax
Email
How did you hear about us?
y
n
Do you prescribe hybrid lenses?
y
n
Do you prescribe lenses for corneal refractive therapy
CRT) or orthokeratology (Ortho-K)?
y
n
Do you prescribe multifocal lenses?
y
n
Do you prescribe scleral lenses?
y
n
Does your practice have multiple locations?
If yes how many?
Place Your First Order (optional):
Patient's Name
OD K Readings
OS K Readings
OD Manifest Rx
OS Manifest Rx
54 Toric
54 Sphere
59 Toric
59 Sphere
49 Toric
49 Sphere
54 Bifocal
54 Multifocal
Lens Type
Multifocal contact lens only:
OD
OS
Eye Dominance:
Pupil Size (2.0 to 6.5 in
0.5mm increments)
Ambient
Bright Light
Pupil Size measurement
recorded in what type of light: