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1New Glasses Rx Form
Patient Name:
Date:
Registration #:
Expires:
Address:
L/R
Sphere
Cyl
Axis
Add
Prism
L
R
L
R
Recommendations
Anti-Reflective Coating
Bifocal
Digital Measurements
Hi-Index Plastic
No-Line Progressive
Photochromic
Polarized
Polycarbonate
Progressive
Single Vision
Trifocal
Tint
Other:
O.D. Signature:
New Glasses Rx Form
Patient Name:
Date:
Registration #:
Expires:
Address:
L/R
Sphere
Cyl
Axis
Add
Prism
L
R
L
R
Recommendations
Anti-Reflective Coating
Bifocal
Digital Measurements
Hi-Index Plastic
No-Line Progressive
Photochromic
Polarized
Polycarbonate
Progressive
Single Vision
Trifocal
Tint
Other:
O.D. Signature:
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Parent category: Medical