New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
2/24/2025 1:38:00 PM
Cost:
70
Service:
Frame + Lenses
prescribed by doctor:
Old RX
Notes:
Bifocal AR + Frame
SPH
CYL
AX
ADD
OD
2.5
2.5
OS
2.5
2.5
Date of visit:
10/8/2025 1:52:00 PM
Cost:
35
Service:
Frame+Lenses
prescribed by doctor:
Old RX
Notes:
bifocal AR change lenses
SPH
CYL
AX
ADD
OD
2.5
2.5
OS
2.5
2.5
New visit Information
Date of visit:
Cost in this visit:
type of service:
prescribed by doctor
Note:
SPH
CYL
AX
ADD
OD
OS
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