Prescription Lens Order Form

Shop / account information

Full shop name * Please enter the shop name.

Account number * Please enter the account number.

Postal code * Please enter the postal code.

Full name * Please enter your full name.

Today's date * Please choose a date.

Frame order #

Phone * Please enter a phone number.

Email * Please enter a valid email address.

Brand / Model / Colour / Size

Enter values exactly as written on your prescription. Leave a box blank if it doesn't apply.

Eye	SPH	CYL	Axis	Add	Prism	Base
OD (right)
OS (left)

Distance PD (mm)

Near PD (mm)

Monocular PD (if applicable) OD / OS

Lens type

Single vision Bifocal (D28) Veri-focal (Pro-Max)

Select a lens type above to see its available lens options.

Your selected lens option is photochromic — please choose a colour.

Photochromic colour

Grey Brown

I confirm the prescription information above is accurate, current, and matches my valid prescription. *

Signature (type full name) * Please type your name to sign.

Date * Please choose a date.