Prescription Form

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Optometri Warisan Sdn. Bhd. 
437340-T
HQ
Lot 39, Bandar Sri Kerteh, 24300 Kerteh, Kemaman, Terengganu. Tel : 09-8264355/0380/0381  Fax : 09-8265431
KL Office
B-1-2 Unit 2, Ist Floor, Block B, Megan Avenue II, Jalan Yap Kwang Seng, 50450 Kuala Lumpur
Tel : 03-21616181/5180 Fax :03-21614180
Web : www.warisansafety.com
Email : warisansafety@yahoo.com.my
 
   PRESCRIPTION FORM – SAFETY EYEWEAR
  
  COMPANY : ____________________________________________
                        

Name

 

Date

 

Employee/IC No.

 

Tel. No. (Office)

 

Location/Dept

 

Handphone No.

 

Email

 

 

 

 

   

PRESCRIPTION RECORD

  Shere Cylinder Axis Prism Addition Dist PD Near PD Fitting Ht
New Prescription R

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

Previous Prescription R

 

 

 

 

 

 

L

 

 

 

 

 

 

FRAME

Brand

 

Model

 

Size

 

Colour

 

  

LENS TYPE

SINGLE VISION   FLAT TOP BIFOCAL   PROGRESSIVE  
CLEAR   TINTED   TRANSITIONS  

    
   

REMARKS :_______________________________________________________________________________
_______________________________________________________________________________

Optometrist/Optician Signature :

 

Name :
Outlet :

I hereby confirm the above information is according to my prescription.

Applicant signature :

 


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