Achternaam (zonder tussenvoegsels) (*)

Voorletters (*)

Tussenvoegsel (van, der, van der etc.)

Voornaam

Geslacht

 Man Vrouw

Geboortedatum* in formaat 31-7-1985:

Adresgegevens:

Straat:

Huisnummer:

Postcode:

Plaats:

Contactgegevens:

Email adres: *

Telefoonnummer:

Indien u ooit een brilrecept gekregen heeft, vul dan de onderstaande velden in. Doe dit ook als u de bril niet meer gebruikt. Het gaat om de gegevens van het laatste brilrecept.

Rechteroog:

OD Spherisch
-10.00-9.75-9.50-9.25-9.00-8.75-8.50-8.25-8.00-7.75-7.50-7.25-7.00-6.75-6.50-6.25-6.00-5.75-5.50-5.25-5.00-4.75-4.50-4.25-4.00-3.75-3.50-3.25-3.00-2.75-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00+4.25+4.50+4.75+5.00+5.25+5.50+5.75+6.00+6.25+6.50+6.75+7.00+7.25+7.50+7.75+8.00+8.25+8.50+8.75+9.00+9.25+9.50+9.75+10.00

OD Cylinder
+5.00+4.75+4.50+4.25+4.00+3.75+3.50+3.25+3.00+2.75+2.50+2.25+2.00+1.75+1.50+1.25+1.00+0.75+0.50+0.250.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00

OD As
0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180

OD Prisma

OD Prisma dioptrie

OD Basis

OD Basis2

OD Nabij

OD V.O.D.

Linkeroog:

OS Spherisch
-10.00-9.75-9.50-9.25-9.00-8.75-8.50-8.25-8.00-7.75-7.50-7.25-7.00-6.75-6.50-6.25-6.00-5.75-5.50-5.25-5.00-4.75-4.50-4.25-4.00-3.75-3.50-3.25-3.00-2.75-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00+4.25+4.50+4.75+5.00+5.25+5.50+5.75+6.00+6.25+6.50+6.75+7.00+7.25+7.50+7.75+8.00+8.25+8.50+8.75+9.00+9.25+9.50+9.75+10.00

OS Cylinder
+5.00+4.75+4.50+4.25+4.00+3.75+3.50+3.25+3.00+2.75+2.50+2.25+2.00+1.75+1.50+1.25+1.00+0.75+0.50+0.250.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00-2.25-2.50-2.75-3.00-3.25-3.50-3.75-4.00-4.25-4.50-4.75-5.00

OS As
0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180

OS Prisma

OS Prisma dioptrie

OS Basis

OS Basis2

OS Nabij

OS V.O.S.

Pupilafstand
40,0040,5041,0041,5042,0042,5043,0043,5044,0044,5045,0045,5046,0046,5047,0047,5048,0048,5049,0049,5050,0050,5051,0051,5052,0052,5053,0053,5054,0054,5055,0055,5056,0056,5057,0057,5058,0058,5059,0059,5060,0060,5061,0061,5062,0062,5063,0063,5064,0064,5065,0065,5066,0066,5067,0067,5068,0068,5069,0069,5070,0070,5071,0071,5072,0072,5073,0073,5074,0074,5075,0075,5076,0076,5077,0077,5078,0078,5079,0079,5080,00

* Verplicht veld