New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
8/22/2024 11:13:00 AM
Cost:
100
Service:
Change lenses Freeform Transtion
prescribed by doctor:
Dr. MOUSA
Notes:
SPH
CYL
AX
ADD
OD
2.5
2.5
OS
2
2.5
Date of visit:
9/19/2024 3:11:00 PM
Cost:
100
Service:
Frame+Lenses
prescribed by doctor:
Dr. Moussa Shoeib
Notes:
freeform progressive + Tiffany & Co Frame
SPH
CYL
AX
ADD
OD
2.5
2.5
OS
2
2.5
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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