New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
8/22/2024 3:20:00 PM
Cost:
30
Service:
Change lenses Colored
prescribed by doctor:
OLD RX
Notes:
SPH
CYL
AX
ADD
OD
0.75
OS
0.5
0.5
170
Date of visit:
9/17/2024 4:36:00 PM
Cost:
85
Service:
Frame + Lenses and Change Lenses
prescribed by doctor:
Old Rx
Notes:
Airlite + Lenses
SPH
CYL
AX
ADD
OD
0.75
OS
0.5
0.5
170
New visit Information
Date of visit:
Cost in this visit:
type of service:
prescribed by doctor
Note:
SPH
CYL
AX
ADD
OD
OS
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