BI-FOCAL PRESCRIPTION FORM - PLEASE ENTER YOUR PRESCRIPTION DETAILS HERE. If you are not sure how to do this, please call us on 01622 755944 to order your prescription. NOTES: SPH and CYL readings will be given as a plus or minus number. The minus symbol may be written above the number as a line - please check carefully for this before filling in the form. The axis is an angle, and will be a whole number. Some prescriptions will not include CYL and Axis readings for one or both eyes (i.e. if you do not suffer from astigmatism). If this is the case, please enter 'zero' in these fields. PD (pupillary Distance) is the distance between the pupils of your eyes. Most people are in the average bracket, in which case this information may not be written on your prescription sheet. If it is there, please enter where shown below. 'Near add' is the bi-focal element of your glasses - this must be entered in every case. Remember - we cannot make prescriptions that are above or below plus / minus 4.50. If you send us a prescription that is unsuitable we will contact you.
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| Your Name
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| Your Email Address
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| SPH, right eye
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| SPH, left eye
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| Cyl, right eye - enter zero if not present
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| Cyl, left eye- enter zero if not present
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| Axis, right eye- enter zero if not present
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| Axis, left eye- enter zero if not present
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| PD (pupillary distance) - enter zero if not known
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| Near add, right eye
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| Near add, left eye
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| Your contact phone number (only used if we have a problem)
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Image Verification
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EMF HTML Contact Form
EMF HTML Contact Form