S-37 Rx Form - US Safety

Prescription Safety Eyewear ProgramPlacing your orderPlacing your order is a two-step process. The first step is to obtain a framesample and order packet from U.S. Safety. Next, you will take your orderpacket and frame sample to your optician for fitting.Step 1 (obtaining a frame sample and order packet)1. View pictures of the Safety Frame Selection and choose an availablestyle, size and color. Tiers 1-4 are covered by Safety-Kleen.2. Print the Order Form and Instructions.3. Fill in the required information on the order form, including framechoice and shipping address, and fax the order to U.S. Safety. If youhave chosen an upgrade frame (Tiers 5 or above), be sure toprovide your credit card information on the order form (see:Employee Paid Options).*4. U.S. Safety will ship a complete order packet to you via First ClassMail, including your choice of frame, Rx order form, ordering instructionsand a postage paid return label.Step 2 (placing an order after receiving your order packet)1. Take the complete order packet, including your frame sample, to youroptician to be measured for your order.2. Have your optician take appropriate measurements and fill in therequired prescription information on the order form.3. Enclose all materials, including the sample frame and completed Rxorder form in the box provided and affix the return shipping label to theoutside of the box. If you have chosen an Employee Paid Option,be sure to provide your credit card information on the orderform (refer to Employee Paid Option pricing included with yourpacket.).*4. Drop the box at any US Postal Service pickup.5. U.S. Safety will manufacture and ship a complete pair of glassesaccording to your order to the address indicated on the order form.6. When you receive your order, check immediately for any problems.Return to your optician if needed for adjustments.* If you do not have a credit card, you can mail your order with a checkor money order payable to: U.S. Safety, P.O. Box 15965, Lenexa, KS66214, Attn: RX Customer Service.Note: The examination and dispensing fees are to be paid by theemployee. Eyeglass prescriptions must not be more than 2 years old.

U.S.SAFETYDivision of Parmelee Industries, Inc.8101 LENEXA DRIVEP.O. BOX 15965LENEXA, KS 66285-5965913-599-55551-800-821-5218Rx FAX 1-800-428-73041-800-252-5002in KansasFAX 1-913-599-1703To Be Completed by Safety Dept.To Be Completed by RefractionistDistanceNear________________________________________ P.O. NO. ___________________Employee Last NameFirst NameCLOCK / ID NO.____________________________ REL. NO.__________________DEPT. ____________________________SEMS AUTH._______________________EMPLOYEE TEL. NO.EMPLOYER__________________________________ ( ) _________________Lens SAF-I-VISION ® OPTILITE ® Glass Clear Tints (Specify Color):Material Polycarbonate (CR39) Plastic Solid _____________________Note: If polycarbonate is not available Optilite will be furnishedGradient _____________________CoatingsPhotochromic (glass)Standard Anti-Reflective UV400 (Std. on polycarbonate)Transitions - Brown / Gray (circle one)Multi-Coat Anti-Reflective Scratch Resistant (Std. on polycarbonate) Polarized - Brown / Gray (circle one)Frame StyleFrame ColorTemple Length Rx Insert CarrierDesc: ________________Rx Insert - see Rx Insert CarrierTint: ________________Eye Size Bridge Size Bridge Style SideshieldsUnifitPermanent Flatfold T-Loc (Only available on Titmus frames)Adj. Pads Detachable Flatfold 40 Wire Mesh CupSphere Cyl. Axis Prism Base Dec. (In-Out)PDRFar NearLRLBold Boxed Areas MUST Be Completed To Process This Order.AddSHIPBILLSeg HgtLamco Safety Products, Inc.P.O. Box 159Hanover, PA 17331Seg WidthSpecialHi-IndexAsphericSlab-OffRoll & PolishThe "US" trademark on the lenses indicates compliance withthe requirements of ANSI Z87.1 & ANSI Z80.1BifocalsFLAT TOP 28 35 Full WidthTrifocalsFLAT TOPCREDIT CARD INFORMATION: ( ) VISA ( ) MC ( ) AMEX AMOUNTDoubleSegmentFLAT TOP 8 x 28 28 8 x 35 35 14 x 35 Non-Std Sep:___________PROGRESSIVEFRAME ONLYCard Number ______________________________________________ Standard ProgressiveDesc: ______________________________Name on Card _____________________________________________Expiration Date ____________________________________________Doctor/Optician Name (Printed)AddressCheck EnclosedCity State Zip Date PhonePLEASE DONOT USECUSTOMER I.D.054545-002-XXXINVOICE NUMBER