Rx Goggles Doctor’s Office Order Form

Prescription Goggles Order Form for Doctor's Office
For a list of participating offices click here.

Child's Information

Please enter the name and age for the child you wish to apply for. Each child will need their own application form submitted.
Your child must be between the age of 4-18 in order to qualify

Parent/Guardian Contact Information

Goggles will be mailed directly to patient's residence within 6 weeks. No rush orders.
Only Ohio residents are eligible at this time.
MANDATORY! Unable to accept @hotmail.com email addresses, please use an alternate email address, such as a close family member or friend's email that you trust can be used if you do not have one of your own.

Doctor Information

Prescription Information

Please contact your child’s eye doctor for this information.

Right Eye OD

Must be 3 numbers even if the first number is zero.

Left Eye OS

Must be 3 numbers even if the first number is zero.

COLORS:

PICTURES ARE TO CHOOSE COLORS ONLY - NOT STYLE OF FRAME. STYLES MX20 and MX21 ARE YOUTH SIZED, STYLES MX30 and MX31 ARE ADULT SIZED.

Eye frame/bridge size

Take your child to a Participating Optical office for measurement or call last place you purchased your child’s glasses and ask for the measurements on those glasses you bought. However, if you choose the latter, there are no refunds or exchanges for 12 months.

MX 20/30 Style:
Has side temples that go over ears and thin short strap across back.

MX 21/31 Style:
No side temples, thick strap all the way around head from lens to lens.

You MUST choose ONE (1) frame size out of the four (4) choices; either Mx20 OR Mx21 OR Mx30 OR Mx31:

The letter of medical necessity can be faxed to OOS Attn: Yvonne at 614-527-6763 when order is submitted. Or you may scan the letter and email it to ytenant@osma.org.

Qualification

Please indicate how you verified the applicant is eligible to participate in this program
***Funded by the Ohio Department of Health, Bureau of Child and Family Health Services and Save Our Sight (SOS) Program. The use of this program to receive a free pair of goggles is contingent upon the availability of grant funding from the SOS program. If funds are exhausted prior to the end of the fiscal year (June 30th) or not renewed for the new fiscal year, the OOS will not be able to complete any orders after such time. We encourage you the next time you renew your vehicle registration to say yes when asked to donate $1 to the Save Our Sight Fund.
Sending