New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 6/30/2025 12:31:00 PM
Cost:: 80
Service:: Frame + Lenses
prescribed by doctor:: dr. prescription
Notes:: AR + transition

	SPH	CYL	AX	ADD
OD	-2	-0.75	50
OS	-1.5

Date of visit:: 2/25/2026 12:57:00 PM
Cost:: 80
Service:: Frame+Lenses
prescribed by doctor:: old rx
Notes:: AR transition w9

	SPH	CYL	AX	ADD
OD	-2	-0.75	50
OS	-1.5

Date of visit:: 2/27/2026 12:57:00 PM
Cost:: 70
Service:: Frame+Lenses
prescribed by doctor:: old rx
Notes:: AR transition w9

	SPH	CYL	AX	ADD
OD	-2	-0.75	50
OS	-1.5

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS