New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/17/2025 3:44:00 PM
Cost:
Service:: Change Lenses
prescribed by doctor:: Old RX
Notes:: AntiBlue Lenses

	SPH	CYL	AX	ADD
OD	0.25	0.5	140
OS	0.25	0.5	35

Date of visit:: 1/20/2025 2:01:00 PM
Cost:
Service:: change lenses
prescribed by doctor:: Nancy
Notes:: AR For near

	SPH	CYL	AX	ADD
OD	3	-0.5	140
OS	3	-0.5	35

Date of visit:: 2/5/2025 4:31:00 PM
Cost:
Service:: Change lenses
prescribed by doctor:: Old RX
Notes:

	SPH	CYL	AX	ADD
OD	3.25	-0.5	62
OS	2.75

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS