Order Form

Would you like to order one of our custom masks? Print out this page and complete the form below.

Mail it to:
Scuba Vision
526 East Perkins
Ukiah, CA 95482

You must include:
[1] Your doctor's prescription
[2] Your mask ("Dot" the location of pupils on mask lens with felt pen.)

Type of lens requested (Circle one.)
Single vision
Bifocal
Reading

Enclose check or money order in U.S. funds in the amount of $129.00 for single vision lenses or $189.00 for bifocal.

Name_______________________________________________

Street_______________________________________________

City____________________State___________Zip___________

Phone_______________________________________________

Please allow 1 - 2 weeks delivery for each mask.

Dealer and Dive Store Inquiries Welcome