UVEX Prescription Goggle Order Form

  1. If your prescription lists more information than Sphere, Cylinder, Axis and Pupillary Distance,   
    you must call your order in to 1-800-777-4733.

  2. Far PD (Pupillary Distance) may be shown as one or two numbers.
    (example: 33/32 or a total of numbers =65mm)

  3. Near PD for Bifocal will be smaller than that of your Far PD.
    (example: 32/31 or 63mm)

                                                                                  Price List

Shipping Information

 One pair of goggles per order form.

Name:

Company:
Address:
Please use street addresses, UPS cannot ship to PO Boxes.
City: , State: Zip:
Country:

Shipping Preference
Phone: Fax:
Email:
Can we email you new product information and special offers?

Prescription and Goggle Information
This information is on your prescription

(1) RX: R (O.D.): Sphere, Cylinder, Axis
(2) RX: L (O.S.): Sphere, Cylinder, Axis
(3) PD: Far (R), Near (R)
Far (L), Near (L)

(4) ADD: for Bifocal:

R-O.D., L-O.S.

  Goggle Options:                          *Maximum eye protection for light sensitive eyes.

    Single Vision Copper Color $189.00
    Single Vision Sun Sensor Changeable or             Eagle Vision*/ Polarized ___ $269.00
    Standard Bi-Focal $249.00
    Standard Bi-Focal Sun Sensor Changeable or     Eagle Vision*/ Polarized ___ $329.00
    Progressive Bi-Focal $289.00
    Progressive Bi-Focal Sun Sensor Changeable or Eagle Vision*/ Polarized ___ $369.00
    Anti-Fog (Extreme Conditions)  add $5.00 (included with complete order)
    Hard Goggle Storage Case add $20.00 (included with complete order)
    Custom Tint Color $25.00 
 

    Frame Color:

       

                                          Credit Card Information

Credit Card Type:
Credit Card Number: (13-16 digits)
Credit Card Billing Address
Credit Card Name as it appears on card:  
Expiration Date:
Total:  Goggles + cost of options + cost of shipping.

Questions, comments, or special requests:

You can print & fax this form to 702-870-0413.

Upon receiving your order, a Customer Service Representative will confirm your order via email.

To place an order by phone, call 1-800-777-ISEE (4733). 

Customer Service Representative will take your order. Thanks!



3961 W Charleston Blvd.
Las Vegas, NV 89102

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