New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 9/13/2024 6:05:00 PM
Cost:: 25
Service:: Change Lenses
prescribed by doctor:: Aya
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	1.25			2.25
OS	1.5			2.25

Date of visit:: 4/5/2025 1:51:00 PM
Cost:: 25
Service:: Frame+Lenses
prescribed by doctor:: Old RX
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	3.5
OS	3.75

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS