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1
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2
Full Name
*
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First Name
Last Name
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3
Phone Number
*
This field is required.
Area Code
Phone Number
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4
E-mail
*
This field is required.
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5
O.D. (RIGHT EYE)
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6
SPH
*
This field is required.
is the first number on your prescription when reading it from left to right. This is used to determine if you are near sighted or far sighted.
-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
-6.50
-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
SPH
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7
CYL
*
This field is required.
Cylinder (Cyl) is the second number on your prescription when reading it from left to right. In combination with your AXIS, Cylinder determines whether you have astigmatism.
-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
-5.00
-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
CYL
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8
AXIS
*
This field is required.
The Axis is the last number on your prescription when reading it from left to right. It should be a number from 1 to 180. This number tells us where to place the cylinder corrections. If you did not have a cylinder correction (cylinder was left blank or said something like SPH or DS) you will not have an axis number.
0.00
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180
0.00
1
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180
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9
ADD
The Add power is for reading or up close vision. It's usually a number between +1.00 to +3.00, it progresses in quarter (0.25) increments. It may also be labeled as near vision (NV). If you want your new glasses to include a bifocal or progressive (no line), we will need this number.
0.00
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
0.00
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
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10
O.S. (LEFT EYE)
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11
SPH
*
This field is required.
is the first number on your prescription when reading it from left to right. This is used to determine if you are near sighted or far sighted.
-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
-6.50
-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
SPH
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12
CYL
*
This field is required.
Cylinder (Cyl) is the second number on your prescription when reading it from left to right. In combination with your AXIS, Cylinder determines whether you have astigmatism.
-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
-5.00
-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
CYL
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13
AXIS
*
This field is required.
The Axis is the last number on your prescription when reading it from left to right. It should be a number from 1 to 180. This number tells us where to place the cylinder corrections. If you did not have a cylinder correction (cylinder was left blank or said something like SPH or DS) you will not have an axis number.
0.00
1
2
3
4
5
6
7
8
9
10
11
12
13
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90
91
92
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96
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98
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100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
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125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
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141
142
143
144
145
146
147
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149
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153
154
155
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159
160
161
162
163
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180
0.00
1
2
3
4
5
6
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9
10
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12
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82
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84
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90
91
92
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96
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98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
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129
130
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155
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159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
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14
ADD
The Add power is for reading or up close vision. It's usually a number between +1.00 to +3.00, it progresses in quarter (0.25) increments. It may also be labeled as near vision (NV). If you want your new glasses to include a bifocal or progressive (no line), we will need this number.
0.00
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
0.00
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
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15
PUPIL DISTANCE
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16
RIGHT mm
Pupil Distance (PD) measures the distance between your pupils in millimeters. PD may not be listed on your prescription. To obtain your PD, call your optician or the last place that made you prescription glasses and ask for your PD on record.
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17
LEFT mm
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18
COMBINED
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19
Comments?
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