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Liquid Polarized Prescription Eyewear

Full Name:
Phone Number:
E-Mail:
Doctor's Name:
Doctor's Phone Number:
Prescription Expiration:

For simplicity, please FAX YOUR PRESCRIPTION to (443) 339-0074, including the specifications, instead of filling out this optional information:

Pricing on prescription insert and lenses will be an additional charge separate from sunglasses. Please complete all purchases for other Liquid accessories and non RX sunglasses before ordering.

Optional

	Sphere	Cylinder	Axis
OD/Right:
OS/Left:

	Add
Bifocal/Right:
Bifocal/Left:

Pupilaric Distance: (Measured in millimeters)	Left:	Right:
Segment Height: (Bifocals Only)

I will use my RX Insert with:

A pair of Player Sunglasses I already own

A pair of Player Sunglasses I plan to purchase (not included)

A pair of Gasket Sunglasses I already own

A pair of Gasket Sunglasses I plan to purchase (not included)

A pair of Titans Sunglasses I already own

A pair of Titans Sunglasses I plan to purchase (not included)

Note: if you need to purchase a pair of Players, Gaskets or Titans in addition to your prescription inserts, complete this form and click the Continue Shopping button on the next page. You will then be able to add the sunglasses you select to your shopping cart.

Lens Options	Price	Select

Single Vision	169.00

Bifocal	199.00

Progressive Bifocal	299.00

Material	Price	Select

Polycarbonate	included

Polished Edge	included

Wrap Compensation (8 Base)	included

Disclaimer:
RX lenses not available in Arizona.

No Refunds or Exchanges on RX Lenses

Certain prescriptions with higher powers may require higher lens cost,
if this is the case we will contact you with a new quote.

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Got Questions? Watch This Instructional Video

Liquid Eyewear Foam and Optical Insert

This video shows how Liquids can be used for prescription sunglasses and goggles. You can change your optical insert from normal to optional foam, which helps keep wind and dust from your eyes. This replaces the need for traditional goggles and allows you to only carry one pair of glasses. This shows the horse shoe case that allows you to store two pairs of sunglasses in one place.

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Adjustable fit instructions Foam Insert Instructions Polarized Sunglasses LTD

Liquid Polarized Prescription Eyewear

I will use my RX Insert with:

Lens Options

Material

Got Questions? Watch This Instructional Video

Liquid Eyewear Foam and Optical Insert