Barz Optics | Prescription Form

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Prescriptions Form
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Prescription Glasses Form:

If you are purchasing prescription glasses from BarzOptics, please fill out the form below and click the submit button.

Contact Name:			Comments:
Email:
Phone:
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Address:
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PRESCRIPTION
Fill out or attach prescription. Must include pupillary distance.
		Spherical	Cylindrical	Axis	If the pupillary distance is not included in your prescription, you can get it by calling your opthamologist/optomertrist or the optician that your your last pair of glasses. We cannot have the prescription lenses made for you without the pupillary distance.
Distance Vision	O.D (right)
	O.D (left)

Pupillary Distance		MUST INCLUDE PUPILLARY DISTANCE

INDICATE BRIDGE SIZE
Small	Medium	Large