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Formato de Receta - Examen de la Vista

Lens Prescription Form

Fill in your prescription details. If you’re unsure, upload a photo/PDF of your prescription.

Patient Information

Full Name*

Date of Birth

Email*

Phone / WhatsApp*

Preferred contact method:

Phone WhatsApp Email

Prescription Type

Eyeglasses Contact Lenses Both

Tip: If you select “Both”, please complete both sections below.

Eyeglasses Prescription

Eye	Sphere (SPH)	Cylinder (CYL)	Axis	Add
Right (OD)
Left (OS)

PD Type

PD (Single, mm)

PD Dual (R/L, mm)

PD is often needed for online orders. If you don’t know it, upload your prescription photo below.

Contact Lens Prescription

Eye	Brand	Base Curve (BC)	Diameter (DIA)	Power
Right (OD)
Left (OS)

Wearing Schedule

Notes (optional)

Quantity (boxes)

Prescription Details

Doctor / Clinic

Prescription Date

Expiration Date

Additional Preferences

Upload Prescription (Optional) Upload photo/PDF

Accepted: JPG, PNG, HEIC (if supported), PDF.

Consent

I confirm this information is accurate* I agree to be contacted regarding my order*

Don’t submit sensitive medical notes. This form is for prescription/order details only.

Need help? Upload your prescription photo and we’ll fill it in.