RX Verification

RX Verification

Please provide a valid eye prescription slip or contact details from an eye doctor
Prescription Requirement
According to the Fairness to Contact Lens Consumers Act (FCLCA), we need your valid prescription or eye doctor contact information to verify your eye prescription for the order.
Your Name*
Date, Prescription Issued*

月日期年
date
Date, Prescription Expired*

日期月年
date
Doctor's Name*
Clinic Name*
Clinic Email*
example@example.com
Clinic Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Right Eye (OD)*
Left Eye (OS)*
Upload Prescription Slip

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