Free Eyeglass Prescription

Patient Information:
Patient Name: Jarrett Bailey
Date of Birth: 11/06/2050
Date of Examination: 10/16/2076
Vision Assessment:
Eye | Sphere (SPH) | Cylinder (CYL) | Axis (AXIS) | Add (Near Vision) |
|---|---|---|---|---|
Right (OD) | -2.50 | -1.00 | 180 | +2.00 |
Left (OS) | -2.75 | -0.75 | 175 | +2.00 |
Pupillary Distance (PD):
PD: 62 mm
Additional Information:
Lens Type: Single Vision
Lens Material: Polycarbonate
Coating: Anti-Reflective
Doctor's Information:

Doctor's Name: [YOUR NAME]
License Number: 12345678
Important Notes:
This prescription is valid until: 10/16/2077.
Follow-up examination recommended within 1 year.
For Inquiries:
If you have any questions regarding this prescription, please contact:
[YOUR COMPANY NAME]
Phone: [YOUR COMPANY NUMBER]
Email: [YOUR COMPANY EMAIL]
Disclaimer:
This prescription is tailored to the individual needs of the patient and should only be used as directed. Always consult with your eye care professional for any concerns.
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Streamline your eye care process with the Eyeglass Prescription Template that’s exclusively offered by Template.net. This customizable document is editable in our AI Editor Tool, allowing you to tailor it to your specific needs. Perfect for optometrists and eyewear retailers, it ensures accuracy and professionalism in every prescription you issue.