New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/13/2024 1:03:00 PM
Cost:: 40
Service:: Frame + Lenses
prescribed by doctor:: OLD RX
Notes:: Metal Frame + AR 1.61 Lenses

	SPH	CYL	AX	ADD
OD	-3.75	-1	95
OS	-4	-2	140

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS