Please fill up the manual Rx form BELOW. Double check and click SUBMIT. Note that this will be sent separately for checking and confirmation from our dedicated Optometrist.

RIGHT EYE (SPHERE) *

Please make sure to indicate the sign - minus or no sign for plus) ex. -1.00 or 1.00 For those who doesn't have any power, please write 0.

RIGHT EYE (CYLINDER) *

Please make sure to indicate the sign - minus or no sign for plus) ex. -1.00 or 1.00 For those who doesn't have any power, please write 0.

RIGHT EYE (AXIS) *

For those who doesn't have astigmatism / cyl, please write 0.

LEFT EYE (SPHERE) *

Please make sure to indicate the sign - minus or no sign for plus) ex. -1.00 or 1.00 For those who doesn't have any power, please write 0.

LEFT EYE (CYLINDER) *

Please make sure to indicate the sign - minus or no sign for plus) ex. -1.00 or 1.00 For those who doesn't have any power, please write 0.

LEFT EYE (AXIS) *

For those who doesn't have astigmatism / cyl, please write 0.

ADD *

Applicable for Progressive Lenses ONLY. For single vision wearer, please choose +0.00.

PUPILLARY DISTANCE *

SEGMENT HEIGHT *

Applicable for Progressive Lenses ONLY. For single vision wearer, please write 0.

COLOR *

Photochromic lenses (Brown and Gray Options) / Clear

Name *

First

Last

Email *

your EYE )

Mobile *

Your requirements ( write down your preference ) *

color	silver/black
size	51
bridge	19
temple size	149

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STAMA-8107 (frame and single vision lens with ARC (1.50 index)

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