New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
8/16/2024 11:06:00 AM
Cost:
80
Service:
Fila Frame+ Transtion Lenses
prescribed by doctor:
OLD RX
Notes:
SPH
CYL
AX
ADD
OD
-1.5
-0.25
5
OS
-1.5
-0.5
60
Date of visit:
2/20/2026 12:38:00 PM
Cost:
50
Service:
change lenses
prescribed by doctor:
OLD Rx
Notes:
AR TRANSITION W9
SPH
CYL
AX
ADD
OD
-1.5
-0.25
5
OS
-1.5
-0.5
60
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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