b'RUDY PROJECT | 2023 RX ORDER FORM Place this order online visit: PLEASE PHOTOCOPY & RE-USE rudyprojectdealer.com/rxAcct. Name Acct. #1015 Calle Amanecer CityState/ZipSan Clemente, California92673 Faxed ByPhone# Rx Department 888.860.7597 Fax to: 800.272.5118 Date Patient STEP 1 New OrderRedo Original Order Number ________________Reason For Redo_________________________________________________________STEP 2FRAMEAStyle Color NO LENS ONLY ORDERSBRudy Project to Provide Frame to Come (Rudy Project is not responsible for frames lost in transit if they were not sent in a traceable manner)CRx Direct in FrameInsertDirect ClipOptical Dock D Rydon ShapeClassic RunningGolfStealthSafety ThicknessSTEP 3LENSES (please select only one) RUDY PROJECT PROPRIETARY LENSESPOLAR 3FX HDRIMPACTRX-2 PHOTOCHROMIC 8 BASE ONLY POLYCARBONATE 8 BASE ONLYImpactRX-2 Photochromic Clear to Black ImpactRX-2 Photochromic Clear to Laser Brown (HDR) Polar 3FX HDR Multilaser GreenImpactRX-2 Photochromic Clear to Laser Black ImpactRX-2 Photochromic Clear to Laser Purple (HDR) Polar 3FX HDR Multilaser RedImpactRX-2 Photochromic Clear to Red (HDR) Polar 3FX HDR Multilaser OrangeImpactRX-2 Photochromic Clear to Laser Red (HDR) Polar 3FX HDR Multilaser BlueADDITIONAL LENS OPTIONSPHOTOCHROMIC POLARIZEDMaterialTRIVEXPOLYCARBONATE MaterialTRIVEXPOLYCARBONATEPhotochromatic Grey Photochromatic Xtra Active Grey*Polar3FX Brown (Gold Mirror and Backside A/R) Polarized GreyPhotochromatic BrownPhotochromatic Xtra Active Brown*Polar3FX Grey (Silver Mirror and Backside A/R) Polarized Brown Photochromatic G-15 Xtra Active Polar Grey (Polarized) Polar3FX Racing Red (Blue Mirror & Backside A/RPolarized G15 PolycarbonateOnlySTANDARD COLORS LASER MIRROR (Backside A/R & Mirror Included)Material TRIVEX POLYCARBONATE MaterialTRIVEXPOLYCARBONATEBlue LightAction BrownOrange Laser Black - Smoke w/Silver MirrorLaser Bronze - Brown w/Gold MirrorTransparentGolf 100Smoke Black Laser Blue - Smoke w/Blue MirrorRacing Red - Red w/Blue Mirror YellowZeiss BioChrom+MaterialTRIVEXPOLYCARBONATERefresh / BlueRelax / GreenFocus / YellowBoost/RedSTEP 4(optional)A/R Full Back Blue Light ADD-ONS Solid Mirror with Hydro - Blue / Red / Green /Silver / Gold / Cobalt / Black Custom Tint Flash Mirror with Hydro-Blue / Red / Green /Silver / Gold / Cobalt / Black Lenticular Thinning Xtractive Mirror with Hydro - Blue / Red / Green / Silver / Gold / PinkPrescription ***Min Seg Height - PAL 15 SPHCYL AXIS PD ADD Seg Height***SizePrismLens TypeSingle VisionODProgressiveOSLined Bifocal, Inverted / Shooting lens available. Please call for availability.Special Instructions87'