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Prescription Lens Order Form
Prescription lens order form
Addendum to your frame order — add your prescription details below. Fields marked * are required.
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.
Client & order information
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
Prescription (Rx)
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 (select one)
Please select a lens type.
Lens option (select one)
Select a lens type above to see its available lens options.
Please select a lens option.
Photochromic colour
Your selected lens option is photochromic — please choose a colour.
Please choose a photochromic colour.
Special instructions
Special instructions
Client authorization
I confirm the prescription information above is accurate, current, and matches my valid prescription. *Please confirm your prescription information before submitting.
Signature (type full name) *Please type your name to sign.
