b'TO PLACE THIS ORDER ONLINE VISIT2024 RUDY PROJECT | RX ORDER FORM RUDYPROJECTDEALER.COM/RX PLEASE PHOTOCOPY AND REUSE FORMAccount Name: Account #:City: State/Zip:1015 Calle AmanacerSan Clemente CA 92673 Faxed By: Phone #:Rx Department 888.860.7597Fax to 800.272.5118 Date: Patient:STEP 1 - ORDERNew Order Redo Original Order # Reason For RedoSTEP 2 - FRAME ***NO LENS ONLY ORDERS***A.Rudy Project ProvidedFrame To Come (Dealer Provided) Rudy Project is not responsible for frames lost in transitif they are not sent via a trackable shipping methodB. Model: Color:C. Rx Type: Rx Direct in Frame Rx Insert Optical Dock Rx ShieldD. Rydon Shape: Classic Running GolfStealth Safety Thickness Curva (rydon slim) STEP 3 - LENSES(please select only one lens plus any optional add-ons)IMPACTRX PHOTOCHROMIC - 8 BASE ONLY (PROPRIETARY) PHOTOCHROMICMaterial:IMPACTX Material:TRIVEXPOLYCARBONATE ImpactRX Photochromic 2 Black ImpactRX Photochromic 2 Laser Red (Blue Mirror)Photochromic GreyXtractive Photochromic Grey ImpactRX Photochromic 2 Laser Black (Silver Mirror)ImpactRX Photochromic 2 Laser Brown (Gold Mirror)Photochromic BrownXtractive Photochromic Brown ImpactRX Photochromic 2 Red HDR ImpactRX Photochromic 2 Laser Purple (Blue Mirror)Photochromic G-15Xtractive Photo Polarized GreyPOLAR 3FX - POLARIZED WITH MIRROR AND BACKSIDE A/R INCLUDED POLARIZEDMaterial:TRIVEXPOLYCARBONATE Material:TRIVEXPOLYCARBONATE Polar 3FX Multilaser Green (Grey w/Green Mirror)Polar 3FX Grey (Grey w/ Silver Mirror)Polarized GreyPolarized Red Polar 3FX Multilaser Blue (Grey w/ Blue Mirror)Polar 3FX Brown (Brown w/ Gold Mirror)Polarized BrownPolarized G-15 (Polycarbonate Only) Polar 3FX Multilaser Orange (Brown w/ Orange)Polar 3FX Racing Red (Red w/ Blue - Polycarbonate Only) Polar 3FX Multilaser Red (Grey w/ Red Mirror - Polycarbonate Only)STANDARD LASER MIRROR - MIRROR AND BACKSIDE A/R INCLUDEDMaterial:TRIVEXPOLYCARBONATE Material:TRIVEXPOLYCARBONATE Blue LightSmoke BlackOrangeLaser Black (Grey with Silver Mirror)Laser Bronze (Brown with Gold Mirror) TransparentAction BrownLaser Blue (Grey with Blue Mirror)Racing Red (Red with Blue Mirror) YellowGolf 100Laser Copper (Copper with Silver Mirror)Zeiss BioChrom+ RX SHIELD - Cutline and Tralyx+Material:TRIVEXPOLYCARBONATE Material:POLYCARBONATE Refresh / BlueFocus / Yellow STANDARD LASER MIRROR PHOTOCHROMIC Relax / GreenBoost / RedTransparentSmoke BlackRacing Red (Red with Blue Mirror) Photochromic Grey YellowAction BrownLaser Blue (Grey with Blue Mirror) MIRROR ADD-ONS (optional)OPTIONAL ADD-ONSOrangeGolf 100Laser Black (Grey with Silver Mirror)Blue Mirror A/R FullA/R BacksideA/R Blue Light POLAR 3FX - POLARIZED WITH MIRROR AND BACKSIDE A/R INCLUDEDGreen Mirror A/R BL TintedCustom TintLenticular ThinningPolar 3FX Multilaser Green (Grey w/ Green)Polar 3FX Grey (Grey w/ Silver)Red Mirror Solid Mirror - Red, Blue, Green, Silver, Gold, Black, CobaltPolar 3FX Multilaser Blue (Grey w/ Blue) POLARIZEDOrange Mirror Flash Mirror - Blue, Green, Silver, Gold, Black, Rose Gold Polar 3FX Multilaser Orange (Brown w/ Orange)Polarized GreySilver Mirror Xtractive Mirror - Blue, Red, Green, Silver, Gold, Pink Polar 3FX Multilaser Red (Grey w/ Red)Polarized BrownGold MirrorSTEP 4 - PRESCRIPTIONRx Lens Type: MINIMUM SH PAL 15 FOR RX SHIELD LENSSPHERE CYLINDER AXIS PD ADD SEG HEIGHT SIZE PRISM OC HEIGHT Single Vision OD ProgressiveOSLined Bifocal and Inverted / Shooting lenses also available please call for detailsSpecial Instructions:87'