New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/10/2025 4:31:00 PM
Cost:: 105
Service:: Toric Contact Lenses
prescribed by doctor:: Old Rx
Notes:: Biofinity toric CL by Medicals + Eyedia Solution

	SPH	CYL	AX	ADD
OD	1	-3.5	35
OS	1.75	-4	155

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS