(1) ophthalmic information necessary to fabricate or dispense the lenses accurately, including the lens manufacturer, lens series, and the lens material, if applicable;

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(2) the diameter, axis, add power, cylinder, peripheral curve, optical zone, and center thickness, where applicable;

(3) power and base curve;

(4) name, license number, telephone number and, for written orders, the signature of the prescribing optometrist or ophthalmologist;

(5) patient’s name and address, expiration date of the prescription, and number of refills or lenses permitted; and

(6) the date of issuance.