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

PLEASE FILL OUT FORM BELOW SHOPPING CART!

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