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Spectacle Rx
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SAN JOSE OFFICE
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Spectacle Rx OD
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Spectacle Rx OS
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ADD (+)
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PD
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Rx Comments:
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Recommendations
• • •
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Expires 2 year
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Prescriber
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Contact Lens Rx
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New Field
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Brand OD
• • •
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Power OD
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Brand OS
• • •
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Power OS
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Instructions:
• • •
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Replacement Frequency
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Contact Lens Warning/Expiration
• • •
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Signature
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Expires 1 year
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Electronic Signature
• • •
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