Prescription Information Collection Form

Prescription Information

Please fill out your prescription information carefully so we can provide you with the most accurate service.

1. Personal Information

Your Name *

Email *

Backer Number *

2. Prescription Details

Right Eye (OD)

Sphere (SPH)

Cylinder (CYL)

Axis

Left Eye (OS)

Sphere (SPH)

Cylinder (CYL)

Axis

3. Pupillary Distance (PD)

Single PD

4. Additional Information (Optional)

ADD (For Reading/Progressive Lenses)

Right (R)

Left (L)

Prism

Right Value

Right Base

Left Value

Left Base

5. Upload & Notes

Upload Prescription File (Optional)

If you have a photo or scan of your prescription, please upload it here. Supports JPG, PNG, PDF.

Notes or Special Instructions (Optional)

I have read and agree to the Terms of Service and Privacy Policy.*