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Fill out your prescription for:
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Right Eye
Left Eye
Both Eyes
Right Eye (OD)
Right Eye (OD)
POWER/SPHERE
*
Please Select
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
-2.50
-2.75
-3.00
-3.25
-3.50
-3.75
-4.00
-4.25
-4.50
-4.75
-5.00
-5.25
-5.50
-5.75
-6.00
-6.25
-6.50
-6.75
-7.00
-7.25
-7.50
-7.75
-8.00
-8.50
-9.00
-9.50
-10.00
-10.50
-11.00
-11.50
-12.00
-12.50
-13.00
-13.50
-14.00
-14.50
-15.00
-15.50
-16.00
-16.50
-17.00
-17.50
-18.00
-18.50
-19.00
-19.50
-20.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.50
+7.00
+7.50
+8.00
+8.50
+9.00
+9.50
+10.00
+10.50
+11.00
+11.50
+12.00
+12.50
+13.00
+13.50
+14.00
+14.50
+15.00
+15.50
+16.00
+16.50
+17.00
+17.50
+18.00
+18.50
+19.00
+19.50
+20.00
BC
*
Please Select
8.8
8.4
D/N
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Please Select
D
N
DIAMETER
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Please Select
14.4
ADD
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Please Select
1.00
1.50
2.00
2.50
3.00
3.50
4.00
CYL
*
Please Select
-0.75
-1.25
-1.75
-2.25
-2.75
-3.00
-3.25
-3.75
-4.25
-4.75
-5.25
-5.75
AXIS
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Please Select
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
10
Left Eye (OS)
Left Eye (OS)
POWER/SPHERE
*
Please Select
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
-2.50
-2.75
-3.00
-3.25
-3.50
-3.75
-4.00
-4.25
-4.50
-4.75
-5.00
-5.25
-5.50
-5.75
-6.00
-6.25
-6.50
-6.75
-7.00
-7.25
-7.50
-7.75
-8.00
-8.50
-9.00
-9.50
-10.00
-10.50
-11.00
-11.50
-12.00
-12.50
-13.00
-13.50
-14.00
-14.50
-15.00
-15.50
-16.00
-16.50
-17.00
-17.50
-18.00
-18.50
-19.00
-19.50
-20.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.50
+7.00
+7.50
+8.00
+8.50
+9.00
+9.50
+10.00
+10.50
+11.00
+11.50
+12.00
+12.50
+13.00
+13.50
+14.00
+14.50
+15.00
+15.50
+16.00
+16.50
+17.00
+17.50
+18.00
+18.50
+19.00
+19.50
+20.00
BC
*
Please Select
8.8
8.4
D/N
*
Please Select
D
N
DIAMETER
*
Please Select
14.4
ADD
*
Please Select
1.00
1.50
2.00
2.50
3.00
3.50
4.00
CYL
*
Please Select
-0.75
-1.25
-1.75
-2.25
-2.75
-3.00
-3.25
-3.75
-4.25
-4.75
-5.25
-5.75
AXIS
*
Please Select
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
10
Section End
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Doctor Information
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Doctor's First Name
Doctor's Last Name
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Office/Clinic Name
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Office/Clinic Street Address
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City
State
Zip
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Office/Clinic Email
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Office/Clinic Phone
Office/Clinic Fax
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