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

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*

Browse Files

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

3M 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

Interspiro

336-890-493 Fits: Spiromatic, Spiromatic-S, Spirotek96496-01 Fits: Divator MKII

MSA

10144230 Fits: G1

NORTH by Honeywell

760024 Fits: 7600 & 5400 Series

OTS Ocean Technology Systems

920033-000 Fits: Guardian

S.E.A.

50023 Fits: SE400, SE46, SE40

Sundström

SR 341 Fits: SR 200

Insert not listed

Brand & Model

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 (Select one)*

$10 (covers shipping insert back to you once lenses are installed.)Email quote for Canada or Europe Shipping Charges. DO NOT MAKE PAYMENT BELOW IF QUOTE IS REQUIRED.

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

Select your insert model

Add-on Options