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Final Prescription
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Issue Rx for glasses
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Issue Rx for contacts
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Name
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Date
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Final Glasses Rx
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OD Sphere
• • •
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OD Cyl
• • •
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Axis OD
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OS Sphere
• • •
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OS Cyl
• • •
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OS Axis
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Glasses use
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Final Contacts Rx
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CL OD SPHERE
• • •
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CL OD Cyl
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CL OD Axis
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CL OD Brand
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CL OS SPHERE
• • •
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CL OS Cyl
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CL OS Axis
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CL OS Brand
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Contact Lens Wear Schedule
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Expiration
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Physician
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Doctor License
• • •
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Once Rx Details have been added above, please change appointment status to "Read to Prescribe"
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