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Prescription Safety Glass Order Form

Employee Name *

EIN or S.S.# *

Plant # *

Provider # *

Eligibility # *

O.D. Prescription Details

OD Sphere

OD Cyl

OD Axis

OD Add

OD Seg Height

OD Seg Width

OD Prism

OD Base Curve

O.S. Prescription Details

OS Sphere

OS Cyl

OS Axis

OS Add

OS Seg Height

OS Seg Width

OS Prism

OS Base Curve

Distance R

Distance L

Near R

Near L

Frame

Style

Color

Model

Eye Size

Bridge

Temple

Side Shields

Detachable
Permanent

Lens

Material

Style

Tint

Other Options

Scratch Coat
UV Filter
AR Coat

Form Submitted By:

Dr. Name

Company

Address

Phone

Provider #

Special Instructions

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