Please provide the details of the eye care professional who issued this prescription. This information is crucial for verifying prescription validity.
Optometrist/Clinic Full Name
Prescription Issue Date
Date of Comprehensive Eye Examination
Prescription Expiration Date
Upload Official Prescription Document (PDF or clear photo)
Upload Pupillary Distance Measurement Photo (if available)
Is this your first-ever optical prescription?
Confidence Level in Prescription Accuracy
Register each family member who will be using this prescription archive. This helps organize multiple prescriptions within a single household.
Number of Family Members Needing Eyewear
Family Member Basic Information
Full Name | Age | Relationship | Primary Vision Need | |
|---|---|---|---|---|
0 | Self | General Use | ||
Enter the complete prescription details for each family member. For OD (Right Eye) and OS (Left Eye), Sphere (Sph) values can be negative (myopia) or positive (hyperopia). Cylinder (Cyl) and Axis are for astigmatism correction. Leave fields blank if not applicable.
Comprehensive Prescription Archive Table
Family Member Name | Vision Correction Type | OD Sphere (Sph) | OD Cylinder (Cyl) | OD Axis (°) | OS Sphere (Sph) | OS Cylinder (Cyl) | OS Axis (°) | Pupillary Distance PD (mm) | ADD (for Bifocal/Progressive) | Prism Correction? | Prism OD | Prism OS | Contact Lens Base Curve (BC) | Contact Lens Diameter (DIA) | Contact Lens Brand/Model | Special Notes | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Distance | -2.5 | -0.75 | 180 | -2.25 | -0.5 | 175 | 62 | 2.5 | 0 | 0 | 0 | 0 | |||||
Do any prescriptions include Bifocal or Progressive lenses?
Do any family members wear Contact Lenses?
Specify your preferences for lens materials and coatings. These choices impact durability, clarity, weight, and cost.
Preferred Lens Material
Standard Plastic (CR-39)
Polycarbonate (Impact-Resistant)
High-Index 1.67 (Thinner)
High-Index 1.74 (Ultra-Thin)
Trivex (Lightweight & Durable)
No Preference
Essential Lens Coatings & Treatments
Anti-Reflective (AR) Coating
Scratch-Resistant Coating
UV400 Protection
Blue Light Filter
Anti-Fog Coating
Hydrophobic Coating
Oleophobic Coating
Do you want Photochromic (Transition) Lenses?
Do you need Tinted Lenses for Specific Activities?
Provide frame preferences and measurements to ensure proper fit. You can find these numbers printed on the inside of your current frames (e.g., 52-18-140).
Current Frame Model Number (if re-ordering)
Frame Width (Lens Width + Bridge Width, mm)
Lens Width (mm)
Bridge Width (mm)
Temple Length (mm)
Preferred Frame Material
Acetate (Plastic)
Metal (Stainless Steel)
Metal (Titanium)
Metal (Aluminum)
TR90 (Flexible Polymer)
Wood/Bamboo
Mixed Materials
No Preference
Frame Style Preference
Full-Rim
Semi-Rimless
Rimless
Oversized
Cat-Eye
Aviator
Round
Square
Rectangle
Oval
Wayfarer
Frame Color Preferences
Black
Tortoise Shell
Clear/Transparent
Silver
Gold
Gunmetal
Blue
Red
Green
Pink
Purple
Brown
Bridge Fit Type
Standard Fit
Low Bridge Fit (Asian Fit)
Adjustable Nose Pads
Saddle Bridge
Keyhole Bridge
Do you need Safety or Sports Eyewear?
Understanding your daily visual demands helps recommend the most suitable eyewear solutions for each family member.
Average Daily Wear Hours
Primary Visual Activities (select all that apply)
Computer Work/Office
Reading/Books
Driving (Day)
Driving (Night)
Smartphone/Tablet Use
Gaming
Watching TV
Outdoor Sports
Indoor Sports
Hobbies/Crafts
Childcare
Construction/Manual Labor
Art/Design Work
Rate Your Current Digital Screen Usage
Outdoor Exposure Frequency
Rarely (<1 hour/day)
Occasional (1-3 hours/day)
Moderate (3-6 hours/day)
High (6+ hours/day)
Very High (Work Outdoors)
Describe Any Issues with Current or Previous Eyewear
Specify your purchasing preferences to help streamline the ordering process when you're ready to buy.
Eyewear Quantity & Budget per Family Member
Family Member Name | Number of Glasses Pairs Needed | Budget per Pair (USD) | Urgency Level | Total Estimated Budget | |
|---|---|---|---|---|---|
1 | $250.00 | Normal (1-3 weeks) | $250.00 | ||
$0.00 | |||||
$0.00 | |||||
$0.00 | |||||
$0.00 | |||||
$0.00 | |||||
$0.00 | |||||
$0.00 | |||||
$0.00 | |||||
$0.00 |
Do you have Vision Insurance Coverage?
Insurance Policy/Member ID
Upload Insurance Card (Front & Back)
I consent to storing this information for future eyewear purchases and understand I should verify all details with my optometrist before ordering.
Provide any medical information that may affect eyewear selection or fit. This ensures safe and appropriate recommendations.
Existing Eye Conditions or Diagnoses
Myopia (Nearsightedness)
Hyperopia (Farsightedness)
Astigmatism
Presbyopia
Cataracts
Glaucoma
Macular Degeneration
Dry Eye Syndrome
Strabismus (Eye Turn)
Amblyopia (Lazy Eye)
Diabetic Retinopathy
None of the Above
Allergies to Materials or Solutions
Do you experience frequent headaches or eye strain?
Do you have any facial structure considerations affecting frame fit?
Additional Special Requirements or Instructions
Emergency Contact Person
Emergency Contact Phone
Digital Signature (Type Full Name)