New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 4/15/2025 6:24:00 PM
Cost:: 60
Service:: Frame + Lenses
prescribed by doctor:: OLD Rx
Notes:: Sting Pink Frame + AR Lenses

	SPH	CYL	AX	ADD
OD	-0.75	-1.25	170
OS	-1	-1	175

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS