| Send or FAX the completed form to: | Or Phone in the order to: | |
| elton Optical | Toll Free 1-800-636-9270 / (702) 895-7340 | |
| 3175 W. Ali Baba Ln. #803 | ||
| Las Vegas, NV 89118 |
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Name: ________________________________________________ Day Phone:_________________
Address: ______________________________________________ Evening Phone: ______________
City: ________________________________________ State: ____________ Zip: _______________
Name of Frame: _____________________________________________________
| Lens Material: | Glass | CR-39 (Optical Plastic) | ||
| Lens Type: | Single Vision | Bifocals | Progressives | |
| Lens Color: | Grey | Bronze | Eagle 475/ 495* (Amber or Blue Blocking Type) | |
| *available in plastic only |
Attach a copy of your eyeglass prescription from your eye doctor or use it to fill in the form below.
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| Distance P.D. Pupillary Dist. |
R. Eye (O.D.) |
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| Near P.D. Pupillary Dist. |
L. Eye (O.S.) |
Note: You must have a P.D. measurement. This is the measurement between your pupils and is needed for proper placement of the lenses in the frame. Sometimes the eye doctor will leave the P.D. off the written prescription. If they have, just call the last place you got glasses for your P.D., they keep it on file.
Circle your choice:
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Credit Card No. _______________________________________________ Exp. Date: _______________
Name on Card and Billing Address if different from above: ________________________________________
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