Optically Ground Polarized Angler Sunglasses |
| Name | |
| Address | |
| City | |
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| Zip | |
| Home Phone Number | |
| Work Phone Number | |
| Fax Number | |
YOUR PRESCRIPTION |
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| Sphere | Cylinder | Axis | Prism | |
| Right Eye O.D. | ||||
| Left Eye O.S | ||||
| Add | ||||
| Dr.'s Name | ||||
| Dr.'s Phone | ||||
| Rx. Date | ||||
| Pupil Distance | Comments | |||
| 5 CHOICES | ||
| 1. FRAME COLOR The Frame color I would like is brown or grey?
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BROWN
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GREY
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| 2. LENS TINT The lens tint I would like is Brown or Grey/Green Calachrome?
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HIGH CONTRAST BROWN CALACHROME
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MEDIUM CONTRAST GREY/GREEN CALACHROME
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| 3. The desired Prescription I would like is non-prescription or prescription? |
NON-PRESCRIPTION
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YOUR PERSONAL SINGLE VISION OR BI-FOCAL PRESCRIPTION (Pupil Distance Needed) |
| 4. I would like side shields yes or no? |
Yes or No | |
| 5. I would like to purchase a cat-strap and or an OGP Angler hat? |
STRAP or OGP Hat |
Yes or No |
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