CEV 106M

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Have 2 PD numbers

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My prescription includes prism($35.00)

	Vertical (Δ)	Base Direction	Horizontal (Δ)	Base Direction
OD	0 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00	n/a Up Down	0 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00	n/a In Out
OS	0 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00	n/a Up Down	-0 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00	n/a In Out

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* By checking this box, you affirm that you possess a valid eyeglass prescription that is less than two (2) years old and issued by a licensed optometrist or ophthalmologist. You acknowledge that you are solely responsible for providing accurate and up-to-date prescription information upon request.

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