b'RUDY PROJECT | 2020 RX ORDER FORMPLEASE PHOTOCOPY & RE-USEAcct. Name Acct. #1015 Calle Amanecer CityState/ZipSan Clemente, California92673 Faxed ByPhone# Rx Department 888.860.7597 Fax to: 800.272.5118 Date Patient (Rudy Project is not responsible for frames lost in transit if they were not sent in a traceable manner)NO LENS ONLY ORDERSSTEP 1(Check One Only) Rudy Project to provide frame Frame To Come - Customer Service will call with order number(Pre-paid labels are available upon request to US accounts only)STEP 2Must send frame with order number Check here if this is a redo.Original Order Number ________________Reason For Redo__________________________________(use special instructions section for additional info)STEP 3 Must send frame with order number(Check One Only)Frame*(required)Color(required)Rx Direct in Frame Insert / Clip / DockSKU If Rydon Direct Select Lens Shape Rydon Rydon RunningRydon StealthFotonyk With BumpersSTEP 4Specify Lens (Check One) IMPACTRX-2 Digital FreeForm TEK POLYCARBONATE FreeForm SportImpactRX-2 Photochromic Clear to Black BASE ONLY Standard Colors Laser Mirror Polarized with Laser MirrorBlue Light (Backside A/R and mirror(Backside A/R and mirror included)ImpactRX-2 Photochromic Clear to Laser Black included) Polar3FX Brown (Gold Mirror)ImpactRX-2 Photochromic Clear to Red (HDR)Transparent Laser Black - ImpactRX-2 Photochromic Clear to Laser Red (HDR)Action Brown Smoke w/Silver Mirror Polar3FX Grey (Silver Mirror)ImpactRX-2 Photochromic Clear to Laser Brown (HDR)Golf 100 Laser Blue -No Coatings Orange Smoke w/Blue MirrorImpactRX-2 Photochromic Clear to Laser Purple Laser Bronze -Smoke Black Brown w/Gold Mirror Polar3FX HDR BASE ONLYPhotochromic Golf GreenALL BASE CURVES AVAILABLEYellow Racing Red -Polar 3FX HDR Multilaser GreenFixed Tint Polarized GreyPhotochromatic Colors Red w/Blue Mirror Polar 3FX HDR Multilaser RedFixed Tint Polarized Brown Photochromatic Grey Polar 3FX HDR Multilaser OrangePhotopolarized GreyPlease note that lenses Photochromatic Brown Polar 3FX HDR Multilaser Blueare tinted even when notPhotochromatic Xtra Active Grey*Photopolarized Brownactivated by UV Photochromatic Xtra Active Brown*STEP 5 A/R CoatingFull A/RBackside A/RSolid Mirror with Hydro - Blue / Green / Red (looks like Multilaser Orange)Flash Mirror with Hydro- Blue / Silver / GoldXtractive Mirror with Hydro - Blue / Silver / Gold /Green / Pink / RedSpecial InstructionsSTEP 6 Prescription SPHCYL AXIS PrismADD Seg Height*** Mono PD****Lens SizeOCLens TypeSingle VisionODProgressiveOS***Min Seg Height - PAL 15****Min 58PD71'