Proclear 1-Day - 90 pack

*Prescription Submission Options:

• You have my prescription on file already
• I will fax a copy to (1-412-422-0105)
• I will upload an image below
• Please call my doctor with the information I will provide below

*Patient Name

*Date Of Birth

-010203040506070809101112 -01020304050607080910111213141516171819202122232425262728293031 -190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016

Doctor's Name

Doctor's Phone #

Upload Your Prescription

Allowed file extensions to upload: *.jpg, *.png

Both Eyes One Eye

	Right (OD)	Left (OS)	One Eye
Quantity	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Power (Sph) Power (Sph)	Choose -12.00 -11.50 -11.00 -10.50 -10.00 -9.50 -9.00 -8.50 -8.00 -7.50 -7.00 -6.50 -6.00 -5.75 -5.50 -5.25 -5.00 -4.75 -4.50 -4.25 -4.00 -3.75 -3.50 -3.25 -3.00 -2.75 -2.50 -2.25 -2.00 -1.75 -1.50 -1.25 -1.00 -0.75 -0.50 -0.25 +0.00 +0.25 +0.50 +0.75 +1.00 +1.25 +1.50 +1.75 +2.00 +2.25 +2.50 +2.75 +3.00 +3.25 +3.50 +3.75 +4.00 +4.25 +4.50 +4.75 +5.00 +5.50 +6.00 +6.50 +7.00 +7.50 +8.00	Choose -12.00 -11.50 -11.00 -10.50 -10.00 -9.50 -9.00 -8.50 -8.00 -7.50 -7.00 -6.50 -6.00 -5.75 -5.50 -5.25 -5.00 -4.75 -4.50 -4.25 -4.00 -3.75 -3.50 -3.25 -3.00 -2.75 -2.50 -2.25 -2.00 -1.75 -1.50 -1.25 -1.00 -0.75 -0.50 -0.25 +0.00 +0.25 +0.50 +0.75 +1.00 +1.25 +1.50 +1.75 +2.00 +2.25 +2.50 +2.75 +3.00 +3.25 +3.50 +3.75 +4.00 +4.25 +4.50 +4.75 +5.00 +5.50 +6.00 +6.50 +7.00 +7.50 +8.00	Choose -12.00 -11.50 -11.00 -10.50 -10.00 -9.50 -9.00 -8.50 -8.00 -7.50 -7.00 -6.50 -6.00 -5.75 -5.50 -5.25 -5.00 -4.75 -4.50 -4.25 -4.00 -3.75 -3.50 -3.25 -3.00 -2.75 -2.50 -2.25 -2.00 -1.75 -1.50 -1.25 -1.00 -0.75 -0.50 -0.25 +0.00 +0.25 +0.50 +0.75 +1.00 +1.25 +1.50 +1.75 +2.00 +2.25 +2.50 +2.75 +3.00 +3.25 +3.50 +3.75 +4.00 +4.25 +4.50 +4.75 +5.00 +5.50 +6.00 +6.50 +7.00 +7.50 +8.00
Base curvature (BC) Base curvature (BC)	8.7	8.7	8.7
Diameter (Dia) Diameter (Dia)	14.2	14.2	14.2

* Required Fields