New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/9/2025 3:41:00 PM
Cost:: 18
Service:: Change Lenses
prescribed by doctor:: Nancy
Notes:: Old frame, AR Lenses

	SPH	CYL	AX	ADD
OD	-2.5	-1	5
OS	-2.5	-0.75	165

Date of visit:: 9/15/2025 4:14:00 PM
Cost:: 40
Service:: Frame+Lenses
prescribed by doctor:: Nancy
Notes:: AR compressed

	SPH	CYL	AX	ADD
OD	-2.75	-1	180
OS	-2.75	-0.75	165

Date of visit:: 7/20/2026 2:56:00 PM
Cost:: 40
Service:: Frame only
prescribed by doctor:: Old Rx
Notes:: Airlite

	SPH	CYL	AX	ADD
OD
OS

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS