New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:
Cost:
Service:: Eye examination
prescribed by doctor:
Notes:

	SPH	CYL	AX	ADD
OD	1			1.5
OS	1.5	-0.75	160	1.5

Date of visit:: 4/24/2025 3:23:00 PM
Cost:: 30
Service:: Frame + Lenses
prescribed by doctor:: Nancy
Notes:: AR

	SPH	CYL	AX	ADD
OD	1
OS	1.5	-0.75	160

Date of visit:: 3/1/2025 4:29:00 PM
Cost:: 20
Service:: Change lenses
prescribed by doctor:: Nancy
Notes:: AR for near

	SPH	CYL	AX	ADD
OD	2.5
OS	3

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS