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Contact Lens Order Form

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Prescription Options
I am a patient at your practice. Please use my current prescription. If this is more than 12 months old, I agree to come in for a consultation for a new prescription. I am not a patient of your practice. I will fax, scan and email or deliver by hand a bone fide copy of my latest prescription on the optometrist’s letterhead which is not more than 12 months old Please indicate if you are an existing patient.
Prescription
RIGHT LENS Base Curve Sph Cyl Axis Add 8.37.48.58.68.78.88.99.0 +20.00+19.75+19.50+19.25+19.00+18.75+18.50+18.25+18.00+17.75+17.50+17.25+17.00+16.75+16.50+16.25+16.00+15.75+15.50+15.25+15.00+14.75+14.50+14.25+14.00+13.75+13.50+13.25+13.00+12.75+12.50+12.25+12.00+11.75+11.50+11.25+11.00+10.75+10.50+10.25+10.00+9.75+9.50+9.25+9.00+98.75+8.50+8.25+8.00+7.75+7.50+7.25+7.00+6.75+6.50+6.25+6.00+5.75+5.50+5.25+5.00+4.75+4.50+4.25+4.00+3.75+3.50+3.25+3.00+2.75+2.50+2.25+2.00+1.75+1.50+1.25+1.00+0.75+0.50+0.250.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00-10.25-10.50-10.75-11.00-11.25-11.50-11.75-12.00-12.25-12.50-12.75-13.00-13.25-13.50-13.75-14.00-14.25-14.50-14.75-15.00-15.25-15.50-15.75-16.00-16.25-16.50-16.75-17.00-17.25-17.50-17.75-18.00-18.25-18.50-18.75-19.00-19.25-19.50-19.75-20.00 n/a0.00-0.25-0.75-1.25-1.75-2.25-2.75-3.25 n/a102030405060708090100110120130140150160170180 n/a+1.00+1.25+1.50+1.75+2.00+2.25+2.50		LEFT LENS Base Curve Sph Cyl Axis Add 8.37.48.58.68.78.88.99.0 +20.00+19.75+19.50+19.25+19.00+18.75+18.50+18.25+18.00+17.75+17.50+17.25+17.00+16.75+16.50+16.25+16.00+15.75+15.50+15.25+15.00+14.75+14.50+14.25+14.00+13.75+13.50+13.25+13.00+12.75+12.50+12.25+12.00+11.75+11.50+11.25+11.00+10.75+10.50+10.25+10.00+9.75+9.50+9.25+9.00+98.75+8.50+8.25+8.00+7.75+7.50+7.25+7.00+6.75+6.50+6.25+6.00+5.75+5.50+5.25+5.00+4.75+4.50+4.25+4.00+3.75+3.50+3.25+3.00+2.75+2.50+2.25+2.00+1.75+1.50+1.25+1.00+0.75+0.50+0.250.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00-5.25-5.50-5.75-6.00-6.25-6.50-6.75-7.00-7.25-7.50-7.75-8.00-8.25-8.50-8.75-9.00-9.25-9.50-9.75-10.00-10.25-10.50-10.75-11.00-11.25-11.50-11.75-12.00-12.25-12.50-12.75-13.00-13.25-13.50-13.75-14.00-14.25-14.50-14.75-15.00-15.25-15.50-15.75-16.00-16.25-16.50-16.75-17.00-17.25-17.50-17.75-18.00-18.25-18.50-18.75-19.00-19.25-19.50-19.75-20.00 n/a0.00-0.25-0.75-1.25-1.75-2.25-2.75-3.25 n/a102030405060708090100110120130140150160170180 n/a+1.00+1.25+1.50+1.75+2.00+2.25+2.50
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