New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/15/2025 10:55:00 AM
Cost:: 90
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: tomford frame , AR TRANSITION

	SPH	CYL	AX	ADD
OD	-0.75
OS	-0.75

Date of visit:: 6/30/2026 4:25:00 PM
Cost:: 110
Service:: Frame+Lenses
prescribed by doctor:: Old Rx
Notes:: Antiblue green coated

	SPH	CYL	AX	ADD
OD	-0.75	-1	160
OS	-0.75	-0.5	25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS