H d rx order form 2015

Page 1

2015 Harley-Davidson® Performance Eyewear by Wiley X

Phone: +45 96 93 03 43

Wiley X Europe LLC Søndergade 8-10 7570 Vemb, Denmark

FOR WILEY X USE ONLY

Fax: +45 96 93 00 40 www.wileyx.eu

****PLEASE CONSULT WILEY X FOR CYLINDERS ABOVE -4.00**** STEP 1

BUYER INFORMATION PATIENT NAME:

Dealer Name / Billing Address / Delivery Address:

ACCT#

Name:

DATE:

Phone #

Birthday:

Contact Name:

Reference:

Dealer E-mail Address:

STEP 2

CHECK BOX FOR YOUR FRAME THEN CIRCLE YOUR COLOR CHOICE

HD ECHO

GLOSS BLACK / MATTE BLACK

HD ZEN

GLOSS BLACK

HD REBEL

GLOSS BLACK / TORTOISE BROWN

HD GRAVITY

MATTE BLACK / CRYSTAL METALLIC / GLOSS BLACK

HD SLAY

MATTE BLACK

HD DRIVE

GLOSS BLACK / MATTE BLACK

HD CURVE

GLOSS BLACK / COTTON CANDY

HD ZAK

MATTE BLACK

HD CRUISE X

GUN METAL / GLOSS BLACK

HD ROUT

GLOSS BLACK

HD CENSOR

MATTE BLACK

HD RANGER

MATTE BLACK

HD JAKE

GLOSS BLACK

HD MOJO

GLOSS BLACK METALLIC COFFEE

HD AIRRAGE

MATTE BLACK / GLOSS BLACK / CRYSTAL BRONZE

HD TWISTED

MATTE BLACK

HD BRICK

MATTE BLACK / CRYSTAL METALLIC / METALLIC BLACK

HD ABBY

ESPRESSO BROWN / RED SUNGLOW / CANYON BROWN

HD SHADOW

STEEL STREAK / MATTE BLACK / GLOSS BLACK / DRAGON

HD CHELSEA

LIQUID PLUM

HD ZONE

TORTOISE BROWN / MATTE BLACK

HD LACEY

COTTON CANDY

HD GEM

DARK TORTOISE FADE / MATTE BLACK / BLACK STREAK

HD GRIT

MATTE BLACK

HD TANK

PEARL BLUE / MATTE BLACK / GLOSS BLACK

HD MOTION

CHARCOAL PEARL / MATTE WHITE

ADDITIONAL COATINGS CHOOSE RX TYPE, LENS COLOR & TYPE BELOW

STEP 3 RX TYPE

LENS COLOUR

LENS TYPE

CLEAR SINGLE VISION

GREY

POLARIZED GREY POLARIZED

SMOKE GREEN YELLOW BROWN

TRANSITION BROWN

TRANSITION GREY

TRANSITION SOLFX

POLARIZED GREEN

FIRE BROWN

THUNDER BROWN

POLARIZED YELLOW

POWER PURPLE

TRUE GREY

ORANGE

STEP 4

TRANSITION

POLARIZED BROWN

TRANSITION

YOUR PRESCRIPTION SPHERE (SPH)

POWER MIRROR COATINGS

POLARIZED

CYLINDER (CYL)

ORANGE MIRROR

RED MIRROR

GREEN MIRROR

SILVER MIRROR

BLUE MIRROR

GOLD MIRROR LENS COATINGS

HMC COATING (STANDARD)

TRANSITION XTRACTIVE GREY

GLACIER COATING

DRIVEWEAR PHOTOCROMIC POLARIZED (GREEN)

GLACIER PLUS COATING

AXIS

R (OD) L (OS)

FAX THE ORDER TO +45 96 93 00 40 OR SEND AN E-MAIL TO HD-INFO@WILEYX.EU FAST PRESCRIPTION SUPPLY (8-10 WORKING DAYS) ORDER WILL BE DELAYED IF INFORMATION IS MISSING OR INCORRECT IN STEPS 1-4

PUPIL DISTANCE (PD)

PUPIL HEIGHT (PH)


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