Eschenbach Haus Call Telelowvision Program

Product Trial Kit Order Form

Account #:

Account Name:

Date:

Purchase Order #:

Placed by:

Phone:

Doctor or staff member to contact with passwords and/or Telelowvision Program review (required):
Name:
Email:

Shipping Information

Patient Name:

Patient Phone:

Street Address:

Unit #:

City:

State:

Zip:

Preferred date of virtual appointment (min. of 14 business days after date of order):

Ship via: Regular (regular shipping included in price)
Other shipping options (surcharge applies): 3-day 2-day Overnight AM Overnight PM

Product Trial Kit Options – Check One

Product Trial Kit with optional iPad (TLV-2P)
Product Trial Kit previously purchased as part of a Complete System

With iPad

Without iPad (Check one)

Please provide Sales Order #:

Special Instructions:

Prepacked Items (TLV-5#): Automatically included in each kit

Product Number Product Name
TAE-24150 Solar Shield® Gray Large Absorptive Filters
TAE-24353 Solar Shield® Amber Large Absorptive Filters
TAE-24357 Solar Shield® Yellow Large Absorptive Filters
TAE-2435P Solar Shield® Plum Large Absorptive Filters
TAE-3H10600654 Night Drivers Large Absorptive Filters
TAE-10601514 Haven® Summerwood Light Rose Absorptive Filters
1663-25015 Ambelis® Large Brown Frame 50-15% Absorptive Filters
1624-11 MaxTV® Telescopic Glasses
1624-21 MaxTV® Clip Telescopic Glasses
1512-2 Mobilux® LED 3x Square Hand-held Magnifier
1511-3 Mobilux® LED 3.5x Square Hand-held Magnifier
1511-4 Mobilux® LED 4x Square Hand-held Magnifier
1511-001 Mobase Stand for 3x, 3.5x, 4x Hand-held Magnifier

If you would prefer to not have the prepackaged items in your Haus Call kit, please opt out here

If opting out, please add the alternative products you would like included in the kit below:

Alternative Products For Kit

Product Number Bracketing* if Possible? Notes
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

*Bracketing involves offering a similar device one unit of measure stronger and lower than that ordered to allow for any variances in the needs required for the object(s) being viewed. For absorptive filters, different frame sizes or tints will be used.

Once form is completed, save and submit to customerservice@eschenbach.com

www.eschenbach.com | (800) 487-5389

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