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Prescription Form

Product Name Lens Name Lens type Action

Customer Details

PRESCRIPTION TYPE - Single-vision

Be sure to select the correct value (+ / -) for both Sphere and Cylinder.

Distance RIGHT EYE LEFT EYE
SPH CLY Axis SPH CLY Axis

Prescription Note:

PD - PUPILLARY DISTANCE (Optional)

  • Single PD

  • Dual PD

PRESCRIPTION TYPE - Bi-focal

Be sure to select the correct value (+ / -) for both Sphere and Cylinder.

Distance RIGHT EYE LEFT EYE
SPH CLY Axis SPH CLY Axis
Reading

ADD:

Prescription Note:

PD - PUPILLARY DISTANCE (Optional)

  • Single PD

  • Dual PD

PRESCRIPTION TYPE - Progressive

Be sure to select the correct value (+ / -) for both Sphere and Cylinder.

Distance RIGHT EYE LEFT EYE
SPH CLY Axis SPH CLY Axis
Reading

ADD:

Prescription Note:

PD - PUPILLARY DISTANCE (Optional)

  • Single PD

  • Dual PD

PRESCRIPTION TYPE - contact-lens

Be sure to select the correct value (+ / -) for both Sphere and Cylinder.

Distance RIGHT EYE LEFT EYE
SPH CLY Axis SPH CLY Axis

Prescription Note:

PD - PUPILLARY DISTANCE (Optional)

  • Single PD

  • Dual PD

PRESCRIPTION Image

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