Online Form - VR Insert Rx Lenses

Interested in Our Special Promo (Package Price $149 and FREE Domestic Shipping) *

Yes! No Not Sure...

Patient's Name *

First

Last

Patient's Date of Birth (MM/DD/YYYY) *

Parent/Gaurdian Name (If Patient Under 18) *

First

Last

Phone Number *

Email *

Home/Shipping Address *

Line 1

Line 2

City

State

Zip Code

Country

Is Billing the same as Shipping Address?? *

Yes No

(If "No'", Please enter billing information below)

Billing Information: (Street, City, State, Zip, and Country) *

Single Vision Price Ranges
Mild Rx: +3.00 to -3.00 |$168.00
Strong Rx: +3.25 or Higher | -3.25 or Higher

Please email or upload a copy of the original Rx. We will not process the order until we receive a copy of your prescription.
(Our Email Address: billcurran2020@gmail.com) Please email us your Rx ASAP if you are not uploading it within the form

Upload Photo Copy of Rx *

Max file size: 20MB

Additional information. (Eye Disorders, Etc.) *

- Optional Lens Add-On But We Highly Recommend Anti Coating Regardless if it's Avance or Blue Light Blocker -

Which A/R Coating Tier are You Interested In? *

A/R Coating (Basic Tier) $99 Extra A/R Prevencia Coating w/ Blue Light Blocker (Top Tier) $199 Extra Not Sure... No Thanks, I'll Pass

Prevencia™: Light can be beneficial in your everyday life!!

Light is fundamental for vision.

Color perception, shapes and details.

Blue-Turquoise Light aids in your overall well-being.

Sleep/wake cycles, memory and basic mental functioning.

- The VR Insert Can Be Inserted onto the Oculus Device Two Different Ways -
(We Prefer Magnets at the Top for Max Comfort) | If you click "Not Sure..." then we will recommend Magnets @ the Top

Disclaimer: If you have an Astigmatism (Cyl and Axis) on your Rx then by changing magnet orientation will effect your vision. Single Vision Spheres Only (Ex: +3.00 or -2.00) can use ANY orientation.

Pick Your Prefered Magnets Orientation *

Magnets at the Top (Recommended Position) Magnets at the Nasal (Nose) Not Sure....

Magnets at the Top

Magnets at the Nasal

Step #8: Send Us a Facial Photo of the Patient (18-20 Inches Away)
This is for the PD (pupillary distance) Oculus Refers to IPD (Inter Pupillary Distance) which is the same thing

1 photo with a standard size business card or license ID
(hold it horizontally under your nose with no eyewear on)

Photo Holding Card Under Nose *

Max file size: 20MB

Note: All fields with an **** are a mandatory field. Forms won't go through otherwise.
Make sure to hit the submit button when you're finished. If mandatory fields are left unanswered, they will be circled in red.

SEEING THE VR WORLD CLEARER