1. 1

   Enter your rx and quantity per eye

   Edit
   Right Eye

   Base Curve

   8.6

   • 8.6

   -- Please Select --8.6

   Diameter

   14.1

   • 14.1

   -- Please Select --14.1

   Power

   Select

   • -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
   • -5.25
   • -5.50
   • -5.75
   • -6.00
   • -6.50
   • -7.00
   • -7.50
   • -8.00
   • -8.50
   • -9.00
   • -9.50
   • -10.00

   • +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

   -- Please Select ---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 -5.25 -5.50 -5.75 -6.00 -6.50 -7.00 -7.50 -8.00 -8.50 -9.00 -9.50 -10.00 +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

   Quantity *

   1

   • 0
   • 1
   • 2
   • 3
   • 4

   -- Please Select --0 1 2 3 4

   Left Eye

   Base Curve

   8.6

   • 8.6

   -- Please Select --8.6

   Diameter

   14.1

   • 14.1

   -- Please Select --14.1

   Power

   Select

   • -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
   • -5.25
   • -5.50
   • -5.75
   • -6.00
   • -6.50
   • -7.00
   • -7.50
   • -8.00
   • -8.50
   • -9.00
   • -9.50
   • -10.00

   • +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

   -- Please Select ---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 -5.25 -5.50 -5.75 -6.00 -6.50 -7.00 -7.50 -8.00 -8.50 -9.00 -9.50 -10.00 +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

   Quantity *

   1

   • 0
   • 1
   • 2
   • 3
   • 4

   -- Please Select --0 1 2 3 4

2. 2

   Verification

   Edit

   How can we verify your RX? *

   • Upload
   • On File
   • Email

     Please e-mail a picture or scan of your RX to rx@lookingglassvision.com

   -- Please Select --Upload On File Email

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