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- Bill to company name and address
- Purchase order or blanket order number
- Employee's name, identification number
- Body of prescription
- Single Vision
- Distance portion of prescription.
- Distance decentration and/or pupillary distance (PD).
- Plus or minus signs (+ -) must appear on all sphere and cylinder powers.
- All cylinder powers must have an axis.
- Bifocal, Trifocal, and Double Segment Bifocal (Multi-Focal)
- In addition to the Single Vision information supplied, for Bifocal be sure "Near" section is filled in with power add.
- Type of Multi-focal.
- Width of Multi-focal.
- Segment height pertaining to type of Multi-focal.
- Segment inset and/or Near PD.
- Specify Lens Material (Glass, Plastic, Plastic Stratch Resisteance, Polycarbonate)
- Indicate Tint if Required
- Specify Extras (UV400), Etc.
Frame Information
- Frame Style and Color
- Select correct sizes that apply to frame selected.
1. eye size
2. bridge size
3. temple length
- First choice of Frame Color
- Second choice of Frame Color
- If side shields are required please indicate type.
Note: Sometimes a frame will be back ordered by the Frame Manufacturer. If you would please select a second choice for color we would be able to avoid long delays.
To download the prescription form, click on the images below.
You will need Adobe Acrobat Reader to view the PDF files, click here to download the reader.
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