New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/23/2025 6:26:00 PM
Cost:: 30
Service:: Frame + Lenses
prescribed by doctor:: Luna
Notes:: Acetate Black and White Frame + AR Lenses for NEAR

	SPH	CYL	AX	ADD
OD	1.75
OS	1.75

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS