Grape Pop

Email the following info  To luxuryshadez@gmail.com 

Please copy and paste form to make it easier for production

Single Vision-   Near, Intermediate or Distance

SPH CYL             AXIS                          ADD                          

OD (Right)                                                                                                                                    

OS (LEFT)                                                                                                     

(PD) Pupillary Distance                                                           if two PDs ☐

Progressive-   Near, Intermediate, and distance in one lens

                           SPH                   CYL                     AXIS            PRISM          

OD (Right)                                                                                                                                         

OS (LEFT)                                                                                                     

(PD) Pupillary Distance                                                           if two PDs ☐

                                                                                                                                          

Reading Glasses- One magnification field for Reading

-Readers- Select a magnification Strength

(Example +0.25, +0.50, +0.75 and Up to +6.00)

List a magnification Strength Here                                                            

 

Type of Prescription

• Single Vision
• Progressive
• Readers- Strength

• Lense Type

  • Standard Lenses $10.00 ☐  Blue Light Blocking $25.00 ☐

    Photo chromatic Lenses $40.00 ☐ Color Tint $45 ☐  Driving Lenses $40.00 ☐
• Lens index

  • The higher index you choose, the thinner the lenses will be

    ☐ 1.57 Mid- Index $10.00  ☐ 1.61 High-Index – RECOMMENDED $25.00

     ☐1.67 High Index $55.00   ☐1.74  High Index $150.00

• Coating

  ☐ Standard Coatings- Reduces light reflections $10.00

  ☐Advanced Coating (Recommended) Water-resistant, easy to clean reduces light reflections $15.00

  ☐Ultimate Coatings $20.00

  ☐No Coating –FREE

  To start production all items must be

  PAID IN FULL