Optical Rx Orders | Prescription Glasses

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Account Name*
To which of your locations should we have this order shipped to?
[For Multi-door accounts Only]
Order Date*
Date Format: MM slash DD slash YYYY
Contact Name*
PO / Ref# / Patient Name*
Contact Email*
Single Vision Rx
Sphere OD*
Cylinder OD
Axis OD
Distance PD OD*
Sphere OS*
Cylinder OS
Axis OS
Distance PD OS*
Prism OD
Base
Prism OS
Base
Progressives
ADD
Seg Height / OC Height
Frame
Style*
Color*
*
- GUNNAR- Supply Frame
- Edged Lenses Only
Lens Material
*
- Polycarbonate
- Trivex
- High-Index 1.67
Lens Type
*
- SV Digital
- Conventional Progressive
- Computer progressive "Office"
- Computer Progressive "Desk"
- +0.25 Power Boost- Anti-Fatigue
- +0.50 Power Boost- Anti-Fatigue
- +0.75 Power Boost- Anti-Fatigue
Lens Tint
*
- Amber (BLPF 65)
- Amber Max (BLPF 98)
- Clear (BLPF 35)
- Amber-Transitions (BLPF 65/90)
- Clear-Transitions (BLPF 35/90)
- Sun
Prescription
Please upload a VALID copy of the patient's actual SIGNED prescription. Note that this document must be valid and signed and is required by US law before we can start the order.
Upload a File
Notes / Comments
*Double-sided A/R coating included on the lenses*

Single Vision Rx