New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/11/2024 10:36:00 AM
Cost:: 11
Service:: CONTACT LENSES
prescribed by doctor:
Notes:: Clear 55

	SPH	CYL	AX	ADD
OD	-2.5
OS	-3

Date of visit:: 3/29/2025 2:30:00 PM
Cost:: 600
Service:: Contact Lenses
prescribed by doctor:: Old Rx
Notes:: Clear 55 (Discount) for 600,000 LBP

	SPH	CYL	AX	ADD
OD	-2.5
OS	-3

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS