New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 4/9/2025 1:43:00 PM
Cost:
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: AR

	SPH	CYL	AX	ADD
OD	-1.75	-2	176
OS	-2.5	-2	150

Date of visit:: 3/27/2025 4:41:00 PM
Cost:: 100
Service:: Frame+Lenses
prescribed by doctor:: OLD Rx
Notes:: Tomford + AR + Transition W9

	SPH	CYL	AX	ADD
OD	-1.75	-2	176
OS	-2.5	-2	150

Date of visit:: 7/7/2025 12:05:00 PM
Cost:: 35
Service:: change lenses
prescribed by doctor:: Old RX
Notes:: AR TRANSITION W9

	SPH	CYL	AX	ADD
OD	-1.75	-2	178
OS	-2.5	-2	150

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS