Rx Form

STEP 1 - Personal Information

STEP 2 - Lens Options

SAFETY PRICES SHOWN
(Check appropriate box for lens type and color)

standard colors

STEP 3 - Frame Options

STEP 4

YOUR PRESCRIPTION
A high power fee of $20 will be applied to prescriptions higher than -5 to +5
Make sure to put in a plus or a minus to insure the correct prescription is ordered.

R (OD)

L (OS)

STEP 5 - Add-ons (Optional)

standard mirrors

polarized colors

polarized mirrors

light adjusting lenses

extra coating (optional) check box