| A Measurement |
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Sphere |
Cylinder |
Axis |
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| B Measurement |
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OD: |
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| DBL Measurement |
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OS: |
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| ED Measurement |
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ADD: |
OD: |
OS: |
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| Patient's Pupillary Distance (Distance) |
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| Patient's Pupillary Distance (Near) |
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OD Horizontal Prism |
Direction |
OD Vertical Prism |
Direction |
| Optical Center (1/2 of B if blank) |
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PRISM: |
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| C.T. or E.T. for Sagitta (optional) |
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OS Horizontal Prism |
Direction |
OS Vertical Prism |
Direction |
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PRISM:
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