|
Date
|
|
|
For
|
DOB
|
|
Address
|
City, State and Zip
|
|
Phone
|
|
|
Prescription for Glasses
|
|
|
OD Sphere
• • •
|
OD Cyl
• • •
|
|
Axis OD
|
OD Add
• • •
|
|
Base Curve OD
• • •
|
Diameter OD
• • •
|
|
OS Sphere
• • •
|
OS Cyl
• • •
|
|
OS Axis
|
OS Add
• • •
|
|
Base Curve OS
• • •
|
Diameter OS
• • •
|
|
Special Recomendations
• • •
|
|
|
|
|
|
Prescription for Contacts
|
|
|
OD Sphere
• • •
|
OD Cyl
• • •
|
|
Axis OD
|
OD Add
• • •
|
|
Base Curve OD
• • •
|
Diameter OD
• • •
|
|
OS Sphere
• • •
|
OS Cyl
• • •
|
|
OS Axis
|
OS Add
• • •
|
|
Base Curve OS
• • •
|
Diameter OS
• • •
|
|
Special Recomendations
• • •
|
|
|
|
|
|
Signature
|
|
