Company Ordered by Date
Address City State Zip
Tel Fax E-mail
Method of Payment Paypal Credit card Company check Method of Shipment USPS Parcel Priority Mail Fedex Ground
Please print the form and fill in the quantity and fax it to 281-497-4501 or email your order to: kditoptical1@yahoo.com
POLY LENS $ 3.00/pr
STANDARD POWER RANGE:
SPH: 0 to - 6.00 CYL: 0 to -2.00
SPH: 0 to + 4.00 CYL: 0 to -2.00