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