New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/10/2025 4:27:00 PM
Cost:: 40
Service:: Frame + Lenses
prescribed by doctor:: Nancy
Notes:: Antiblue

	SPH	CYL	AX	ADD
OD	-0.5	-0.25	180
OS	-1

Date of visit:: 2/2/2026 3:35:00 PM
Cost:: 65
Service:: Frame+Lenses
prescribed by doctor:: OLD Rx
Notes:: Antiblue

	SPH	CYL	AX	ADD
OD	-0.5	-0.25	180
OS	-1

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS