New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/15/2025 10:21:00 AM
Cost:: 130
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: AR lenses transition

	SPH	CYL	AX	ADD
OD	1.5	1	85
OS	0	0.5	105

Date of visit:: 1/15/2025 10:24:00 AM
Cost:: 30
Service:: change lenses
prescribed by doctor:: OLD Rx
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	1.5	1	85
OS	0	0.5	105

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS