New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 8/15/2024 11:36:00 AM
Cost:: 45
Service:: Change lenses Transtion
prescribed by doctor:: OLD RX
Notes:

	SPH	CYL	AX	ADD
OD	1.25	0.75	140
OS	1.25	0.5	25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS