|
By:
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Responsible Party
|
|
Amount:
|
Paid:
|
|
Balance:
|
|
|
EYEGLASS RX
|
|
|
O.D - SPHERE
|
O.D - CYLINDER
|
|
O.D - AXIS
|
SPECIAL INSTRUCTIONS
|
|
O.S - SPHERE
|
O.S - CYLINDER
|
|
O.S - AXIS
|
SPECIAL INSTRUCTIONS
|
|
Spectacle Rx Expires
|
|
|
SOFT
|
|
|
B.C. - O.D.
|
B.C. - O.S.
|
|
PWR. - O.D.
|
PWR. - O.S.
|
|
DIA. - O.D.
|
DIA. - O.S.
|
|
COLOR - O.D.
|
COLOR - O.S.
|
|
ADD - O.D.
|
ADD - O.S.
|
|
"FILL AS WRITTEN AND SUBSTITUTIONS"
|
|
|
CL Expires
|
Signature
|
