01. Edit your x ray prescription form online
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X ray prescription form 2026
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02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out x ray prescription form with our platform
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Ease of Use
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- Click ‘Get Form’ to open the x ray prescription form in the editor.
- Begin by entering the customer name and order number in the designated fields at the top of the form.
- Select the type of prescription you need by checking one of the boxes: Single Vision, Bifocal, or Progressive. Ensure you understand which option applies to your needs.
- For each prescription type, fill in the required fields such as Sphere, Cylinder, Axis, and Pupilary Distance for both right (OD) and left (OS) eyes. Make sure to verify that your prescription is current for the year.
- Once all necessary information is filled out, review your entries for accuracy before proceeding to fax the completed form to the provided number.
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Related links
Walk-ins for x-rays with a doctors referral/prescription are welcome. New Patients (631) 638-0597 Existing Patients (631) 638-2600
Tell your doctor before getting an X-ray or prescription. Tell your doctor before getting an X-ray or prescription. fillable form - English (PDF) Call 1-800-