New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/23/2025 1:40:00 PM
Cost:: 90
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: Blue cut green coated , RIGHT EYE 1.61

	SPH	CYL	AX	ADD
OD	-0.5	-3.25	25
OS	-0.75	-1.5	18

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS