Address: 12222 Wilshire Blvd., Suite 105, Los Angeles, CA 90025
Tel: (310) 828-2010
Fax: (424) 832-3712
Lic. #: 10047T
Patient Information
Rx for: Lu, Yanxin
Date: 7/5/22
Prescription
Sphere
Cylinder
Axis
Doc
Prism
Base
OD (DIST)
-5.50
-1.25
35
OS (DIST)
-5.50
-1.25
148
ADD
R
L
Bifocal
TYPE
SEG. SIZE
SEG. POSITION
PD
DIST
NEAR
66
Tint
(empty)
Remarks
2nd Pair:
IMPACT RESISTANT, MUST MEET Z-80 STANDARDS. VOID IF ALTERED. VALID FOR 1 YEAR FROM ABOVE DATE.
Notes
FILLING THIS PRESCRIPTION CONSTITUTES AN AGREEMENT TO RE-MAKE LENSES AT MY DIRECTION FOR A PERIOD OF NINETY (90) DAYS WITHOUT FURTHER CHARGE TO ME OR MY PATIENT.
-NOT FOR CONTACT LENSES.