New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 8/20/2024 3:19:00 PM
Cost:: 25
Service:: Change lenses AR
prescribed by doctor:: OLD RX
Notes:

	SPH	CYL	AX	ADD
OD	-3.25
OS	-3.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS