Shivam Optical

Special Features

Eye Prescription for order

Date of Examination:

Patent name:

Age:

Address:

Phone No. (office):

(Resi) (Mob.)

E-mail:

Doctor’s Name & Address to whom Eyes Checked: (optinal)

Doctor’s E-mail:

Phone No.

Spectacle prescription

	(SPH) SPERE	(CYL)CYLINDER	AXIS	(Add) ADDITION
RIGHT EYE (OD)
LEFT EYE (OS)

P.D. mm

1. Wear Type
	Full Time
	Distance only
	Reading only
	Driving only
	Computer work
	Sunglass

2. Lens design
	Single Vision
	Bifocal Kryptop
	Bifocal ‘D’ Bifocal
	Progressive

3. Lens Material
	Plastic
	Mineral Glass
	Polycarbonate
	Photocronic Glass
	Grey Brown
	Transitions
	Grey Brown
	Hi-Index
	Aspheric

4. Lens Treatment
	Anti Reflection Coating
	Plastic Lens Hard Coating
	Ultra Violet Coating
	Water Repellent
	Tint Pink Brown Grey
	Emi Coat for computer
	Crizal*

Remarks:

Contact Lens Prescription

	(SPH) SPERE	(CYL) CYLINDER	AXIS	(Add) ADDITION	Dia. Mm	B.C	Type of lens Brand Mfg.
RIGHT EYE (OD)
LEFT EYE (OS)

	Daily disposible
	Monthly disposible
	Quarterly disposible
	Yearly disposible
	Colors:
	Clear:
	Single vision
	Progressive

Remarks:

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