New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 8/22/2024 10:58:00 AM
Cost:: 50
Service:: Change lenses polycarbonate idol
prescribed by doctor:: Old RX
Notes:

	SPH	CYL	AX	ADD
OD	-2.25
OS	-2.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS