SUBMIT YOUR PRESCRIPTION INFORMATION BELOW

 

Eyewear Prescription Information
Click or drag a file to this area to upload.
Please enter your eyewear prescription information. If you have a pdf or image file of your prescription, please submit it in the file box above and you do not have to fill out the rest of the form. If you do not have a PDF or image of your prescription saved, please enter your information manually below. If you would like to give us permission to get your prescription from your physician, please visit this page: https://www.monroesfootwearsupply.com/consent-of-release-of-medical-records-to-monroe-optical-inc/
Selected Value: 90
Selected Value: 20
Selected Value: 10
IF PRISM IS GREATER THAN 3 PLEASE NOTE IN ADDITIONAL DETAILS BEFORE SUBMITTING
IF PRISM IS GREATER THAN 3 PLEASE NOTE IN ADDITIONAL DETAILS BEFORE SUBMITTING
Please add any extra details to your prescription not listed above.
Selected Value: 90
Selected Value: 20
Selected Value: 10
IF PRISM IS GREATER THAN 3 PLEASE NOTE IN ADDITIONAL DETAILS BEFORE SUBMITTING
IF PRISM IS GREATER THAN 3 PLEASE NOTE IN ADDITIONAL DETAILS BEFORE SUBMITTING
Please add any extra details to your prescription not listed above.