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Brand Proclear Toric
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PLEASE ENTER PRESCRIPTION AND CUSTOMER INFORMATION
1
.
I have ordered from you before.
2.
Use prescription on file
I will fax a copy of my prescription to (800)-617-5367 or will email a scanned copy to contact@prismoptical.com.
Please use my prescription information below.
Please enter your prescription information below which must be verified by us before we can fill your order.
Date of Eye Exam:
Right:
Power
-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
-0.25
0.00
+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
Cylinder
-.75
-1.25
-1.75
-2.25
Axis
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
Base Curve
8.4
8.8
Diameter
14.4
Left:
Power
-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
-0.25
0.00
+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
Cylinder
-.75
-1.25
-1.75
-2.25
Axis
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
Base Curve
8.4
8.8
Diameter
14.4
Below is my doctor's information so you can verify my prescription.
Doctor's Name:
Phone Number:
Ex: 555-555-5555
Practice Name:
City:
State:
Choose One
AB - Alberta
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
BC - British Columbia
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MB - Manitoba
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NB - New Brunswick
NC - North Carolina
ND - North Dakota
NE - Nebraska
NF - Newfoundland
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NS - Nova Scotia
NT - North West Territories
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
ON - Ontario
OR - Oregon
PA - Pennsylvania
PE - Prince Edward Island
PQ - Quebec
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
SK - Saskatchewan
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
YT - Yukon
3.
Date of birth of the person who the order is for.
(mm/dd/yy)
4.
Note any credits, warranties, etc. or any other information regarding your order.
Order Information
Contact Lens Price:
$67.00 Per Box
Please enter the quantity of boxes for both eyes.
(Quantity is required)
Right:
Quantity
0 Boxes
1 Box
2 Boxes
3 Boxes
4 Boxes
5 Boxes
6 Boxes
7 Boxes
8 Boxes
9 Boxes
10 Boxes
11 Boxes
12 Boxes
Left:
Quantity
0 Boxes
1 Box
2 Boxes
3 Boxes
4 Boxes
5 Boxes
6 Boxes
7 Boxes
8 Boxes
9 Boxes
10 Boxes
11 Boxes
12 Boxes
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