You Are Here:
Shop Online
--
Brand Acuvue Advance
--> Customer Information
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
-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
-8.75
-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
-0.25
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
+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
Base Curve
8.3
8.7
Diameter
14.0
Left:
Power
-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
-8.75
-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
-0.25
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
+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
Base Curve
8.3
8.7
Diameter
14.0
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:
$31.00 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
To go back to a previous step, click on the step
below.
You Are Here:
Shop Online
--
Brand Acuvue Advance
--> Customer Information
© 2013 Prism Optical. Website and data engine powered by
Yerasoft
.
