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Sample Delivery Receipt Practice Name Address Phone, FAX, e-mail Name Date Address Sphere Cylinder Axis Prism Base Distance OD OS Add OD Special OS Instructions: Eyeglasses, including the following features: Frame (brand and identifying information) Single vision lens(es) Bifocal lens(es) Trifocal lens(es) Polycarbonate lens(es) Progressive lens(es) Wide segment Balance lens UV filtration Slab off Prism Oversize lens(es) Tint (specify) Anti-reflective coating Scratch coating Deluxe lens features (specify) Other I acknowledge receipt of the eyeglasses described above..