E-Mail Prescription Form

1.To e-mail your prescription please read the directions and fill out the form

2. Copy the form

3. Click on my e-mail address Enter your name on the subject line. and paste the completed form into the body of the e-mail then send.

john@dyslexiaglasses.com

IMPORTANT NOTE: Please use the plus or minus signs as indicated on your prescription. If there is no sign on your Sphere or Cylinder power, please assume that it is a "plus" and use the + sign when you enter the numbers. For example, instead of entering 1.25, please enter +1.25. Thank you!

Sphere Cylinder Axis Prism Base

Distance Right (O.D.)

Left (O.S.)

Add Power Segment Height

Near Right (O.D.)

Left (O.S.)

Enter pupillary distance (Far): Enter pupillary distance (Near - Bifocals only):

You must enter the pupillary distance to assure the center of focus is directly in front of your eyes. Sometimes this information is missing and only recorded by whoever made your glasses.