Prescription Upload Form
Upload a picture, scan or copy of your prescription. Scroll to complete the entire form.
Who Are These Glasses For?
*
First
Last
Your Email address
*
In case we have a question.
Phone Number (In case we have a question about your Rx)
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Area Code
Phone Number
Upload Rx Here
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Upload Rx
Cancel
of
Pupillary Distance (optional)
Anything we should know?
Submit Prescription
Should be Empty: