New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/19/2025 1:33:00 PM
Cost:: 90
Service:: Change Lenses
prescribed by doctor:: OLD RX
Notes:: Progressive infinity pro + montage

	SPH	CYL	AX	ADD
OD	0	0.75	180	2.5
OS	0	0.75	180	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