PATIENTS DETAILS

PRESCRIPTION

RIGHT EYE SPHERE +/-

RIGHT EYE CYL +/-

RIGHT EYE AXIS

PUPIL DISTANCE (P.D.)

LEFT EYE SPHERE +/-

LEFT EYE CYL +/-

LEFT EYE AXIS

* IF YOUR PRESCRIPTION HAS NO CYL AND AXIS PLEASE PUT A 0 OR NONE IN THE BOXES.

ONCE YOU PRESS SUBMIT THE PRESCRIPTION WILL BE SENT TO US AND ALL THE TEXT WILL CLEAR OFF THE SCREEN

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