orderform2

Dear ………………………………………………… (Optometrist / Ophthalmologist)

Please provide our client with 3 prescription powers and distance/near PD.

1. Distance Prescription
Right eye:	Sph:………. / cyl………. X
Left_eye:	Sph:.………./ cyl………. X

Near Prescription
2. Reading Add for 30 cm }Add R:………L:……..
3. Intermediate Add for 40 - 50 cm }Add R:………L:……..

Other instructions:………………………………………

4. Distance PD right eye:….. left eye:….. binocular ………….

5. Near PD right eye:….. left eye:….. binocular ………….

Return prescription to:  Multireaders.info (I-optic 20/20 Vision Centre P/L)
			    476 High St.
			    Penrith NSW 2750 - 
                            ph: 1800 635222 47217080 fax:0247 321106