New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
Cost:
20
Service:
change lenses for near
prescribed by doctor:
Old RX
Notes:
AR Lenses
SPH
CYL
AX
ADD
OD
3.75
OS
3.75
New visit Information
Date of visit:
Cost in this visit:
type of service:
prescribed by doctor
Note:
SPH
CYL
AX
ADD
OD
OS
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