New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/7/2025 1:45:00 PM
Cost:: 20
Service:: Change Lenses
prescribed by doctor:: Old RX
Notes:: AR

	SPH	CYL	AX	ADD
OD	1.25
OS	1.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS