SAFETY PRESCRIPTION R/X ONLY


 

Employee Name:           		 EIN or S.S.#:
Home Address:       
City:     State:             Zip:          
Work Phone:           
 
Rx Sphere Cyl Axis Add Seg
Height		 Seg
Width		 Prism Base
Curve
O.D.              
O.S.              
 
PD
 

L

R

  
Dist:
Near:


Frame:

Style:            Color:           Model:     

Eye Size:             Bridge:            Temple:

Side Shields: Detachable  Permanent

Lens:

Material:           Style:        

Tint:      Other: Scratch Coat  UV Filter  AR Coat


Special Instructions:

 

Bill To:

Company: 
Address:
Phone: 


Form Submitted By:

Dr. Name:  
Dr. Address:  
Dr. Phone: