New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/18/2024 2:45:00 PM
Cost:: 40
Service:: Frame + Lenses
prescribed by doctor:: OLD RX
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	-1	-1.5	90
OS	-1.25	-0.5	75

Date of visit:: 7/17/2025 1:06:00 PM
Cost:: 25
Service:: Frame+Lenses
prescribed by doctor:: dr. Ali Alhaj
Notes:: AR old frame

	SPH	CYL	AX	ADD
OD	0.25	-1.5	90
OS	0	-0.5	75

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS