PRESCRIPTION INFORMATION FORM

Use form to fill in your prescription and measurements. Use specifications box for additional information. Provided information is confidential and is not distributed to any third parties.
If you have additional concerns regarding prescription lenses, contact customer service at (415) 642-1313. Fax: (415) 642-1313 [email protected].
Hours: M-Fri. 12-7pm; Sat. 12-6pm

RIGHT EYE:

SPHERE CYLINDER AXIS        ADD

O.D. PRISM


LEFT EYE:

SPHERE CYLINDER AXIS        ADD

O.S. PRISM



P.D. MEASUREMENT

MONO P.D. RIGHT

MONO P.D. LEFT

SPECIFICATIONS:



Please enter the following code into the box provided: