Prescription

Your Prescription
PLEASE NOTE - These details are important and are essentially the recipe that your glasses are made to. We ask that you double check your details before submiting to confirm all details are correct.

If you have any questions in relation to any of the requested details please don't hesitate to CONTACT US.

One of the most important details in custom making eyewear for you is the P.D. (pupillary distance) measurement. Your Prescriber will have this measurement or can take this measurement and write it on your prescription. Without this we cannot custom make your eyewear to your specifications.

*indicates required fields

*First Name:

*Surname:

*Date of Birth:

*Contact Phone #:

*Street Address:

*Suburb:

*Date of Prescription:

*Name of Prescriber:

*Phone # of Prescriber:

*Right Eye Sphere/SPH:

*Right Eye Cylinder/CYL:

Right Eye Axis (only if CYL present):

*Right Eye Addition/ADD:

Any Other Details Associated with Right Eye:

*Left Eye Sphere/SPH:

*Left Eye Cylinder/CYL:

Left Eye Axis (only if CYL is present):

*Left Eye Addition/ADD:

Any Other Details Associated with Left Eye:

*P.D. / Pupillary Distance:

*Glasse to be used for ....:

Near / Reading / Up Close
Distance / Driving
Both Distance & Near
Computer

Any other notes made by Prescriber:

After completing all the required details simply click on the SUBMIT button and your Prescription details will be forwarded on to us. From here all you need to do is decide on the typr of frame and lens you would like.

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