Safety/Sport Quote

Feeslip tab ID

Frame

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PDs

Measured Seg/OC

Invoiced Seg/OC

Percentage discount

Exact-dollar discount

2nd pair

3rd pair

Must be purchased on same day. If patient opts out now, there will be $50 for frame and $50 for lenses when they need it later

First name initial

Last name

Date of birth

Frame

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Lenses

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Discount

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Warranty

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Final price
Retail total —

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