New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/3/2025 2:55:00 PM
Cost:: 75
Service:: Frame + Lenses
prescribed by doctor:: OLD RX
Notes:: Le Club + AR + Transition W9

	SPH	CYL	AX	ADD
OD	-2.5
OS	-3	-0.5	5

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS