Rx Order Form

VM Products - The Lens Coating Lab

Clearly the best look in town!

Rx Order Form

		SPH.	CYL.	AXIS	PRISM	BASE	DIST PD.	NEAR PD.
VM Products 34 Rickenbacker Circle Livermore, CA 94551 800-444-COTE phone: 925-449-8400 fax:925-449-8458
Patient:								Uncut
DIST	R
DIST	L
						EYE SIZE/A		DBL
		ADD	HEIGHT	OC HGT	BASE CURVE
ADD	R					ED		B
ADD	L

LENS		POLARIZED		SV BIF TRI PROG			LENS COLOR
LENS		PLASTIC HI INDEX POLY TRIVEX
FRAME		ENCL TO COME SUPPLY				FRAME NAME
FRAME		METAL ZYL NYLON				FRAME NAME
SPECIAL INST.						FRAME
						LENSES
						EDGING
						OVERSIZE
						HIGH POWER
						A/R
						TINTING
Your Business Name:						TAX
Your Name:						SHIPPING
Phone #:						TOTAL
Email:

Please Print for your records before placing order