Prescription Eyewear Quote Request

Thank you for ordering your prescription radiation protection glasses from AADCO! We require your prescription information as provided by your physician in order to provide you with an accurate quote. Thank you for being an AADCO customer!

Client Prescription Lens Information

MATERIAL

FRAME

FRAME TYPE

COATING

High Index Or Lentic Lenses Required?

Customer Name(Required)

First Last

Gender(Required)

This information will be used to generate an average Pupillary Distance and / or Segment Height measurement if requested.

Hospital / Business Name(Required)

What email address should we send your quote to?(Required)

REQUIRED FOR ALL EYEWEAR

Please provide us the following basic information about your eyewear prescription.

IMPORTANT: Examine your prescription carefully. Do BOTH of the following statements apply to you? 1. My SPHERE measurement IS between -3.99 and +3.99. AND 2. My CYLINDER (CYL) measurement IS between -1.99 and +1.99.(Required)

Lens Style Required(Required)

Color

REQUIRED FOR READERS: Readers / Magnifiers Only – No Rx

This section is required only if you are ordering readers / magnifiers, and NOT prescription lenses. Please enter level of magnification here:

Reader Magnification

REQUIRED FOR PRESCRIPTION GLASSES: Rx Glasses

This section is only required if you are ordering prescription lenses. Please transcribe your prescription information below, exactly as written by your physician. Please Note: “OD” indicates measurements for the right eye, and “OS” indicates measurements for the left eye.

Sphere

Cylinder

Axis

Prism

Special Base Curve

Center

Edge

Optical Center

Add Power

Dist Dec

Inset

Total Dec

REQUIRED FOR ALL GLASSES: Pupillary Distance & Segment Height

If you know your Pupillary Distance and Segment Height measurements, please enter them here. Otherwise, proceed with consent and acknowledgement for average measurements below.

PD Distance

PD Near

Segment Height

Pupillary Distance – REQUIRED FOR ALL EYEWEAR

Most prescriptions written by your physician will include your pupillary distance measurement. This is the measurement of the distance between your eye’s pupils. If you have this measurement, please indicate in the designated field above. If you do not have this measurement, you may request it from your physician. If you would prefer that we use an average measurement when making your lenses, you may authorize us to do so by providing your consent here:

Segment Height – REQUIRED FOR BIFOCAL, PROGRESSIVE AND READERS / MAGNIFIERS

Segment Height is a measurement only required for bifocal and progressive lenses. It is the vertical measurement from the bottom of the lens in your frames to the beginning of a progressive addition on a progressive lens, or the top line of a lined bifocal. The Segment Height measurement is specific to the frame and to the individual wearing the frame. Variables such as how the frames sit on the face, as well as where your pupils are relative to the frame, will affect this measurement. For this reason, your measured segment height will likely be slightly different in different style frames. You may specify a desired segment height measurement, if known, in the field provided above. If you do not already know your segment height measurement for the specific frames that you are ordering, we are able to provide “dummy frames” that can be marked for segment height by your physician. If you would prefer that we use an average measurement when making your lenses, you may authorize us to do so by providing your consent here:

Generated Average PD Distance (Male)

Generated Average PD Near (Male)

Generated Average PD Distance (Female)

Generated Average PD Near (Female)