Prescription Rx Submission Form

Name on Order

E-Mail Address

Name on Rx

If both your eyes are the same, you might have one set of numbers marked OU (Both Eyes)
If you don't see numbers for some of the boxes (CYL, AXIS or ADD)leave those values blank.

	SPH	CYL	AXIS	PRISM	ADD
OD (RIGHT)
OS (LEFT)
OU (BOTH EYES)

PD (Pupil Distance) REQUIRED

Most PDs are a combined number. Enter the number in the (OU)combined box
Sometimes PDs are given for each eye. Enter accordingly.

	PD
OU (COMBINED)
OD (RIGHT)
OS (LEFT)


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