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Prescription Card
Select Date:
Name:
Phone Number:
City Name:
R.E Distance:
SPH:
--
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
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CLY:
--
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Axis:
R.E Near:
SPH:
--
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
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CLY:
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Axis:
ADD:
--
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L.E Distance:
SPH:
--
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
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CLY:
--
0.00
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-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
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Axis:
L.E Near:
SPH:
--
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
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Axis:
ADD:
--
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+15.00
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