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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:

Optional

	Sphere	Cylinder	Axis
OD/Right:
OS/Left:

	Add
Bifocal/Right:
Bifocal/Left:

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

Select a model:

Player

Gasket

Lens Options	Price	Select

Single Vision	149.00

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.

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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