Trispec/ Complete Eye Safety Rx Spectacle Kit Lens Order Form

Spectacle Kit Lens Processing Order Form

Please complete the form below and submit payment. YOU ARE REQUIRED TO SHIP YOUR INSERT TO OUR LAB SO THE LENSES CAN BE INSTALLED. You are responsible for the cost to ship the insert to our lab. $10 is collected below with your order to cover the shipping back to you once the lenses are installed.

After submitting this form please ship your insert to the address below. A copy of these instructions will be emailed to the email address provided below.

*If shipping USPS the city may appear as Park Hills*

Complete Eye Safety

101 Lore Lane

Leadington, MO 63601

WE DO NOT SHIP OUTSIDE OF THE US.

Questions? Contact Katie

314 281-1509

info@completeeyesafety.com
Name*
E-mail*
Copy of order will be sent here
Phone*
Employer's Name (optional)
Ship completed insert to:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a copy of your prescription*

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Every order must include a PD (pupillary Distance Measurement).

If the PD is not indicated on your Rx please do one of the following to get it.

1. Call your eye doctor's office and ask if they have it on file. They typically do and can give it to you over the phone.

2. Download the free app "PDCheck" on your Apple device and take the PD yourself. This is just like taking a selfie. We need the distance PD number.

The PD will either be one (mono) number typically in the 60's or two (right & left eye) numbers in the 30s.
PD Measurement *
Select your lens type.*

Single Vision Lenses $60Lined Bifocal Lenses $75No-Line Digital Progressive Lenses $100
Select your insert model

All Tradenames and Trademarks are the Property of Their Respective Owners
Insert to Fit 3M (TM) SCOTT Safety

200372-52F Fits: AV-3000200372-60F Fits: AV-3000200371-52F Fits: AV-2000 & Scott-O-Vista200371-60F Fits: AV-2000 & Scott-O-Vista200373-52F Fits: Promask, Promask 25, M120200373-60F Fits: Promask, Promask 25, M120200374-54F Fits: M95 & M110200372-52FC5 Fits: Vision C5200372-60FC5 Fits: Vision C5
Insert to Fit Interspiro (TM)

336-890-493 Fits: Spiromatic, Spiromatic-S, Spirotek96496-01 Fits: Divator MKII
Insert to Fit MSA(TM)

10144230 Fits: G1
Insert to Fit NORTH by Honeywell (TM)

760024 Fits: 7600 & 5400 Series
Insert to Fit OTS Ocean Technology Systems (TM)

920033-000 Fits: Guardian
Insert to Fit S.E.A. (TM)

50023 Fits: SE400, SE46, SE40
Insert to Fit Sundström (TM)

SR 341 Fits: SR 200
Insert not listed
Brand & Model
Add-on Options
Smokesight XT Hi-Definition Yellow Tint +$12
- Helps reduce the effects of smoke and haze
- Relieves eye strain and reduces glare
- Works to improve visibility day and night, indoors and outdoors
- Amplifies lime/yellow and red/orange on firefighter turnout gear and safety vests
- Enhances rifle or pistol shooting targets
True Color Reception Grey Tint +$12
- Reflects and absorbs glare
- Enhances visibility in bright sunlight
- Gives true color reception and will not distort colors
- Relieves eye strain
Tint Options +$12

Add Smokesight XT Yellow Tint +$12Add True Color Reception Grey Tint +$12
Anti-Fog Application Kit (includes spray & cloth) +$20

Add Anti-Fog Kit +$20
Included With Every Order!
- Lightweight impact-resistant polycarbonate lens material
- Ultimate Scratch Resistant Coating
- Ultra Violet Coating
- Hard case
- Microfiber Cloth
- Cleaning Spray
Special instructions
SHIPPING ~ WE ONLY SHIP WITHIN THE US*

$10 (covers shipping insert back to you once lenses are installed.)
Total Amount Due (Please make payment below)

Payment Amount

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I understand I am required to ship my insert to Complete Eye Safety after submitting my order to ensure proper lens installation.*

Yes, I understand.
Ship insert to the address below. Be sure your name is in the box!

*If shipping USPS the city may appear as Park Hills*

Complete Eye Safety
101 Lore Lane
Leadington, MO 63601
Should be Empty:

Select your insert model

Add-on Options