RXSG - Prescription Safety Glasses

Safety Spectacle Order Form

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Safety Spectacle Catalogue

Safety Spectacle Order Form

PSG National Contracts

Contract Order Tracking

Tue, 7 September, 2010

lenses by

PLEASE NOTE: This form is designed for use with Internet Explorer 4 or greater.
Account Details
Account Name:	Remember my details	Account ID:
Patient Details
Patient First Name:		Patient Last Name:
Practice Reference No:

Frame & Coating Details

Prescription Details

Right Eye:

Sphere:

X Axis:

Cyl:

Add:

Height:

Height Type: BOX View Box Format

DOC:

PD:

Near PD:

Left Eye:

Sphere:

X Axis:

Cyl:

Add:

Height:

Height Type: BOX View Box Format

DOC:

PD:

Total PD:

Near PD:

Total Near PD:

I have read the following note regarding Heights measurements:
Please note: The fitting system used at our laboratory is the box measurement system. All measurements are to be in millimetres up from the lowest point of the frame; this job will be fitted as per the box height you specify.

Prism Details

Prism: Right Eye:

Prism: Left Eye:

Cost & Delivery

Delivery Method: Express (per order)