Progressive/bifocal briller

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New prescription

Non prescription FASHION ONLY (0,00 optical glasses)

Sphere (SPH)

Cylinder (CYL)

Axis (AXE)

Right Eye (OD)

Left Eye (OS)

Addition (ADD)

If PD is not known, you may use the average values which are 62mm for women, 64mm for men

Pupil Distance		Measure PD
Eye Pupil Distance	Measure PD
Individual right and left Pupil Distance for progressive glasses.

Prism correction

	Prism value	Prism Base
Right Eye (OD)
Left Eye (OS)

Customer Name

Prescription Type

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(Please note that the additional cost for lenses other than standard single vision is per PAIR of lenses. HMC - Antireflex coating (AR) and Quartz Anti-scratch Hard-coating (HC) is included for all lenses, which it always should be for quality optics.)

Height to eye pupil

If you are ordering progressive glasses, based on a model you already have available, use a non permanent felt pen to make a mark on the lens directly in front of the pupil. Measure the vertical distance from the lower part of the lens to the center of the pupil in millimeters.

	Pupil height If you are ordering progressive glasses, based on a model you already have available, use a non permanent felt pen to make a mark on the lens directly in front of the pupil. Measure the vertical distance from the lower part of the frame to the center of the pupil in millimeters. For all other cases the average pupil height for this model is used
	Height to eye pupil If you are ordering progressive glasses, based on a model you already have available, use a non permanent felt pen to make a mark on the lens directly in front of the pupil. Measure the vertical distance from the lower part of the frame to the center of the pupil in millimeters. For all other cases the average pupil height for this model is used
Individual Right and Left Pupil Height to eye pupil

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Progressive/bifocal briller		$
Selected Lenses:		+$ 0
Selected Lenses For Sunglasses:		+$ 0