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Practice Address
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Spectacle Rx
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Spectacle Rx OD
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Spectacle Rx OS
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Add
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Recommendations
• • •
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Expires 1 year
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Prescriber
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Contact Lens Rx
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Contact Lens OD
• • •
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Other
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Power
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BC/DIA
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Contact Lens OS
• • •
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Other
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Power
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BC/DIA
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Boxes Per Eye
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Replacement Frequency
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Extended Wear
• • •
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Expires 1 year
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Other Instructions
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Prescriber
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