Prescription goggles
doctor’s office
order form

We’ve made it easy. So you can be more super.
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.

Doctor Information
Right Eye OD

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

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

This is a number, N/A not acceptable.

Left Eye OS

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

This is a number, N/A not acceptable.

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.

Goggle Colors

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:
If Yes, choices are: 10, 33 or 100% and is only available in gray.

If Transition Lens is selected, a letter of medical necessity from physician is required. The letter of medical necessity can be faxed to OOS Attn: Twila Trein at 614-527-6762 when order is submitted. Or you may scan the letter and email it to ttrein@osma.org
Confirmation
Please indicate how you verified the applicant is eligible to participate in this program.
There are no returns or exchanges.
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.