Please provide the details of the optometrist who performed the eye examination and the examination date. This information is crucial for validating prescriptions with online retailers.
Optometrist Name
Date of Exam
Clinic/Hospital Name
Optometrist Contact Information
Next Recommended Exam Date
Type of Examination
Routine Annual Check-up
Specific Vision Problem
Contact Lens Fitting
Post-Surgery Follow-up
Other
Please describe the specific vision problem:
Please specify other examination type:
Were any eye diseases or conditions diagnosed during this exam?
Please list diagnosed conditions:
Are these prescriptions valid for online eyewear purchase?
Please consult with your optometrist about obtaining a prescription suitable for online purchase before proceeding.
Enter the optical prescription details for each family member. OD (Oculus Dexter) refers to the right eye, OS (Oculus Sinister) refers to the left eye. Sph (Sphere) indicates lens power, Cyl (Cylinder) corrects astigmatism, and Axis determines lens orientation. PD (Pupillary Distance) is essential for proper lens alignment.
Family Optical Prescriptions
Family Member Name | Vision Type | OD Sphere (Sph) | OD Cylinder (Cyl) | OD Axis | OS Sphere (Sph) | OS Cylinder (Cyl) | OS Axis | Pupillary Distance (PD in mm) | ||
|---|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | I | ||
1 | Primary Account Holder | Distance | -2.5 | -1 | 180 | -2.75 | -0.75 | 175 | 62 | |
2 | Spouse | Reading | 1.75 | 0 | 0 | 1.5 | 0 | 0 | 61 | |
3 | ||||||||||
4 | ||||||||||
5 | ||||||||||
6 | ||||||||||
7 | ||||||||||
8 | ||||||||||
9 | ||||||||||
10 |
Provide additional measurements that affect lens manufacturing and frame selection. These details ensure optimal comfort and visual acuity.
Vertex Distance (mm)
Do any prescriptions include Prism correction?
Enter prism details for each affected family member (e.g., John: 2 PD Base Up OD, 1 PD Base Down OS):
Dominant Eye
Right Eye (OD)
Left Eye (OS)
Not Tested
Varies by Family Member
Do you need bifocal or progressive measurements?
Enter segment height or fitting cross location for each family member:
Do you have separate Near PD and Distance PD measurements?
Near vs Distance PD
Family Member | Distance PD (mm) | Near PD (mm) | ||
|---|---|---|---|---|
A | B | C | ||
1 | Primary Account Holder | 62 | 59 | |
2 | ||||
3 | ||||
4 | ||||
5 | ||||
6 | ||||
7 | ||||
8 | ||||
9 | ||||
10 |
Are you ordering contact lenses?
Contact Lens Specifications
Family Member | Base Curve (BC) | Diameter (DIA) | Brand | Material Type | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Primary Account Holder | 8.6 | 14.2 | Acuvue Oasys | Silicone Hydrogel | |
2 | ||||||
3 | ||||||
4 | ||||||
5 | ||||||
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
Record measurements from existing comfortable frames to ensure new purchases fit properly. These measurements are typically printed inside the temple arm.
Do you have existing frames with comfortable fit measurements?
Current Frame Measurements
Family Member | Lens Width (mm) | Bridge Width (mm) | Temple Length (mm) | Frame Shape | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Primary Account Holder | 52 | 18 | 140 | Rectangle | |
2 | ||||||
3 | ||||||
4 | ||||||
5 | ||||||
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
Frame Material Preferences
Acetate
Metal (Titanium)
Metal (Stainless Steel)
TR90 (Flexible Plastic)
Wood
Carbon Fiber
No Preference
Frame Style Preferences
Full Rim
Semi-Rimless
Rimless
Cat Eye
Aviator
Round
Rectangle
Oval
Wayfarer
Frame Fit Preference
Narrow
Medium
Wide
Extra Wide
Varies by Family Member
Select preferred lens materials, enhancements, and coatings. These options improve durability, visual comfort, and protection.
Preferred Lens Material
Standard Plastic (CR-39)
Polycarbonate (Impact-Resistant)
Trivex (Lightweight)
High-Index Plastic
Varies by Family Member
Preferred Lens Index (Thickness)
Standard (1.50)
Mid-Index (1.56)
High-Index (1.60)
Ultra High-Index (1.67)
Premium High-Index (1.74)
Varies by Family Member
Include Photochromic (Transition) Lenses?
Photochromic Lens Type
Standard Transitions
Transitions XTRActive
Transitions Vantage
Sensity
LifeRx
Other
Include Blue Light Filtering Coating?
Include Anti-Reflective (AR) Coating?
AR Coating Quality Level
Standard
Premium
Ultra Premium (Anti-Static, Hydrophobic)
Varies by Family Member
Include Scratch-Resistant Coating?
Include UV Protection Coating?
Include Anti-Fog Coating?
Help us understand your online eyewear shopping habits and preferences to streamline future purchases.
Have you purchased prescription eyewear online before?
Which online retailers have you used?
Zenni Optical
Warby Parker
EyeBuyDirect
GlassesUSA
Felix Gray
SmartBuyGlasses
FramesDirect
Other
Please specify other retailers:
We recommend researching retailer return policies, warranty terms, and virtual try-on tools before your first purchase.
Most Important Factors When Choosing Online Retailer
Price
Fast Shipping
Easy Returns
Virtual Try-On
Customer Reviews
Wide Selection
Designer Brands
Insurance Acceptance
Rate the Importance of Retailer Features (1 = Not Important, 5 = Extremely Important)
Fast Shipping | |
Return Policy | |
Virtual Try-On | |
Customer Reviews | |
Price Matching | |
Warranty Coverage |
Do you have a preferred online retailer account?
Please list retailer names and account details:
Set budget expectations and payment preferences for future eyewear purchases.
Approximate Budget per Pair of Glasses
Approximate Budget per Contact Lens Supply (Annual)
Do you have Vision Insurance?
Insurance Details
Insurance Provider | Policy/Group Number | Member ID | Coverage Details | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | VSP Vision Care | GRP12345 | MBR67890 | Frames: $150, Lenses: 100% | |
2 | |||||
3 | |||||
4 | |||||
5 | |||||
6 | |||||
7 | |||||
8 | |||||
9 | |||||
10 |
Do you use FSA or HSA for eyewear purchases?
Preferred Payment Methods
Credit Card
PayPal
Apple Pay
Google Pay
Insurance Direct Billing
FSA/HSA Card
Other
Upload scanned copies of original prescriptions and eye exam reports for reference and verification purposes.
Upload Original Prescription Document (PDF or Image)
Upload Eye Exam Report (Optional)
Upload Photo of Current Glasses (Optional)
Additional Notes or Special Requirements
Emergency Contact Name
Emergency Contact Phone
Primary Care Physician Name
Primary Care Physician Contact
Please review and acknowledge the following statements to complete your prescription archive.
I consent to storing my family's optical prescription data in this secure archive for the purpose of facilitating online eyewear purchases.
I acknowledge that I am responsible for ensuring prescription validity and accuracy when submitting to online retailers.
I consent to sharing this prescription data with selected online eyewear retailers for order processing (optional).
Would you like to receive reminders for upcoming eye exam appointments?
Digital Signature (Primary Account Holder)
To configure an element, select it on the form.