Client Prescription Lens Information MATERIALCR-39FRAMEEnclosedFRAME TYPEZYLCOATINGBasic AR, Anti-Scratch CoatingHigh Index Or Lentic Lenses Required?YesYesNoCustomer Name(Required) First Last Gender(Required)Select GenderMaleFemaleThis 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 EYEWEARPlease 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)SelectNoYesLens Style Required(Required)SelectSingle VisionBifocal or Readers / MagnifiersProgressiveColorSelectBlackBlueSilverPatinaItem No.LG-701B+Item No.LG-701K+Item No.LG-701P+Item No.LG-701S+Item No.LG-701BItem No.LG-701KItem No.LG-701PItem No.LG-701SItem No.LG-702B+Item No.LG-702K+Item No.LG-702P+Item No.LG-702S+Item No.LG-702BItem No.LG-702KItem No.LG-702PItem No.LG-702SItem No.LG-703B+Item No.LG-703K+Item No.LG-703P+Item No.LG-703S+Item No.LG-703BItem No.LG-703KItem No.LG-703PItem No.LG-703SREQUIRED FOR READERS: Readers / Magnifiers Only – No RxThis section is required only if you are ordering readers / magnifiers, and NOT prescription lenses. Please enter level of magnification here:Reader MagnificationODOS Add RemoveREQUIRED FOR PRESCRIPTION GLASSES: Rx GlassesThis 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.SphereODOS Add RemoveCylinderODOS Add RemoveAxisODOS Add RemovePrismODOS Add RemoveSpecial Base CurveODOS Add RemoveCenterODOS Add RemoveEdgeODOS Add RemoveOptical CenterODOS Add RemoveAdd PowerODOS Add RemoveDist DecODOS Add RemoveInsetODOS Add RemoveTotal DecODOS Add RemoveREQUIRED FOR ALL GLASSES: Pupillary Distance & Segment HeightIf you know your Pupillary Distance and Segment Height measurements, please enter them here. Otherwise, proceed with consent and acknowledgement for average measurements below.PD DistanceODOS Add RemovePD NearODOS Add RemoveSegment HeightODOS Add RemovePupillary Distance – REQUIRED FOR ALL EYEWEARMost 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: Pupillary Distance Consent I request that AADCO use an average measurement for my Pupillary Distance and acknowledge the following:AADCO Medical, Inc. has advised that I should provide additional information regarding my pupillary distance measurement. I hereby acknowledge that AADCO has requested that this additional information be provided by my optometrist or ophthalmologist to aid in the production of my prescription eyewear. I have decided not to provide this information, and ask that AADCO proceed with the production of the prescription eyewear, without the benefit of a pupillary distance measurement from my physician. I understand and hereby acknowledge that the use of an average pupillary distance measurement in conjunction with my prescription information may provide results that are not optimized and / or that may result in imperfect vision and / or other unpredictable results and / or unpredictable effects. I hereby acknowledge that I shall not hold AADCO accountable for such results or effects and will in fact indemnify and hold AADCO, its employees, officers or assigns harmless for any results or effects that may occur. I also acknowledge and agree that this resulting and personalized eyewear product is not returnable to AADCO for either refund or replacement.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:Segment Height Consent I request that AADCO use an average measurement for my Segment Height and acknowledge the following:AADCO Medical, Inc. has advised that I should provide additional information regarding my segment height measurement. I hereby acknowledge that AADCO has requested that this additional information be provided in consultation with my optometrist or ophthalmologist, or by utilizing “dummy frames” to aid in the production of my prescription eyewear. I have decided not to provide this information, and ask that AADCO proceed with the production of the prescription eyewear, without the benefit of a more accurate segment height measurement. I understand and hereby acknowledge that the use of an average segment height measurement in conjunction with my prescription information may provide results that are not optimized and / or that may result in imperfect vision and / or other unpredictable results and / or unpredictable effects. I hereby acknowledge that I shall not hold AADCO accountable for such results or effects and will in fact indemnify and hold AADCO, its employees, officers or assigns harmless for any results or effects that may occur. I also acknowledge and agree that this resulting and personalized eyewear product is not returnable to AADCO for either refund or replacement.For Internal Use Only – Automatically Generated PD & Segment HeightGenerated Average PD Distance (Male)OD 32 / OS 32Generated Average PD Near (Male)OD 30.5 / OS 30.5Generated Average PD Distance (Female)OD 31 / OS 31Generated Average PD Near (Female)OD 29.5 / OS 29.5Generated Average Segment HeightNot Required for Single Vision LensesGenerated Average Segment Height5 Above CenterGenerated Average Segment Height3 Below CenterClient ConsentConsent(Required) The information provided herein is accurate.I acknowledge that the information that I have provided herein is accurate and request that AADCO Medical, Inc. use all prescription information as it has been submitted to manufacture my protective prescription eyewear.
