"*" indicates required fields Form completed by First Last Order Reference/ PO /Diver Name*Dive Shop/ Optical Shop name*Email* Lens Type*Single Vision (Distance)Bifocal (Distance + Reading)Reading OnlySingle Vision options High Index (If prescription is greater than +/-4) See under (Leave the bottom of the mask without correction if they take off their glasses to read) Bifocal TypeStandardWide Reading ($ ST 35)Right Eye Reader Strength (OD)+ 1.00+ 1.25+ 1.50+ 1.75+ 2.00+ 2.25+ 2.50+ 2.75+ 3.00+ 3.25+ 3.50+ 3.75Left Eye Reader Strength (OS)+ 1.00+ 1.25+ 1.50+ 1.75+ 2.00+ 2.25+ 2.50+ 2.75+ 3.00+ 3.25+ 3.50+ 3.75For reading powers above +3.75 please list in special notes. Reading lenses do not correct for astigmatism- reading lenses with astigmatism correction should be submitted as single vision orders.Mask ModelIf known, please enter the model of the mask being supplied.Processing Time*Standard- Approx 2 business weeks from receipt of mask5 Business Day Rush3 Business Day RushPrescription Upload Drop files here or Select files Max. file size: 50 MB, Max. files: 1. Special Notes/RequestsIf prescription not uploaded- please enter in hereCommentsThis field is for validation purposes and should be left unchanged.
