Prescription lenses order form







    Order number: Name: E-mail:
    Diopter (SPH) Cylinder (CYL) Angle (AX) Addition (ADD)
    Right eye Diopter (SPH) Cylinder (CYL) Angle (A) Addition (ADD)
    Left eye Diopter (SPH) Cylinder (CYL) Angle (A)
    Half PD Fitting height LC distance Pantoscopic tilt
    Right eye Half PD Fitting height LC distance Pantoscopic tilt
    Left eye Half PD Fitting height LC distance
    You can attach a photo

    Information to be printed on the warranty card

    Optic shop name: Optic shop address: Customer name:

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