Rx Order Form
Please take this form to your eye doctor and have him fill it out and sign it…or… you may send us a copy of a recent eyeglass prescription signed by your doctor. Prescription MUST include P.D. Fax to 219-663-4684
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Sphere |
Cylinder |
Axis |
Prism |
Base |
P.D. |
O.D. (right eye) |
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O.S. (left eye) |
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Spherical Power: +/-4.00D Cylindrical Power: +/-2.00D
Total (Combined Sphere and Cylinder) Power: +/- 4.00D
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Doctor’s Name: |
Lic. #: |
Address: |
Date of Rx: |
City, State, Zip: |
Notes: |
Daytime Phone: |
Doctor Signature: |
Patient’s Name: |
E-mail Address: |
Customer Contact: |
MC ÿ VISA ÿ AMEX ÿ DISC ÿ *Prepay by CHECKÿ |
Address: |
Card #: |
City, State, Zip: |
Signature: |
Daytime Phone: |
Name on Card: |
Nighttime Phone: |
Expiration Date: |
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Frame Style |
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Price |
Enter Price |
G200 Phoenix with Rx insert frame |
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$32.99 |
$ |
G202 Eagle Int. Kit |
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$22.95 |
$ |
G102 Int. Sport/Street 2 |
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$32.99 |
$ |
G102J Int. Sport/Street 2, Jack Daniel's |
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$39.99 |
$ |
S303 Raven Padded Glasses (limit +/-3.00) |
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$15.99 |
$ |
B400 Feather2 with Rx insert frame |
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$24.49 |
$ |
G303 Owl |
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$22.99 |
$ |
G101 Falcon |
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$24.95 |
$ |
BE141 Hen |
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$16.99 |
$ |
S400 T-Bird |
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$16.99 |
$ |
S401 Quail |
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$16.99 |
$ |
G110 Gull |
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$16.99 |
$ |
S101 Crow |
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$15.99 |
$ |
B201 Condor |
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$18.99 |
$ |
BE100 Bill |
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$15.99 |
$ |
B202 Ostrich |
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$16.99 |
$ |
Lens Material |
Lens Choice(Circle One) |
Price |
Enter Price |
Polycarbonate |
Clearÿ |
$89.00 |
$ |
Polycarbonate |
Yellowÿ GrayÿBrown |
$89.00 |
$ |
Polycarbonate Polarized |
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$159.00 |
$ |
Polycarbonate Transition |
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$165.00 |
$ |
DriveWear Transitional |
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$195.00 |
$ |
Polycarbonate Lined Bifocal |
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$129.00 |
$ |
Polycarbonate No-Line Bifocal |
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$159.00 |
$ |
Polycarbonate No-Line Transition |
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$250.00 |
$ |
Polycarbonate No-Line Polarized |
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$230.00 |
$ |
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Anti-Reflective Coating (Back side of lens) |
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$40.00 |
$ |
Mirror Coating |
ÿ ÿ ÿ |
$50.00 |
$ |
Heavy Mirror Coating |
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$85.00 |
$ |
Subtotal Lens Price (total of above items listed) |
$ |
IN State Sales Tax @ 6.00% |
$ |
Shipping |
$11.00 |
Total Amount Due |
$ |
Sporting Specs
630 Springwood Drive
Hebron, IN 46341
Fax: 219-663-4684