New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
7/2/2025 2:12:00 PM
Cost:
60
Service:
Frame + Lenses
prescribed by doctor:
OLD RX
Notes:
Metal Frame + Bifocal Lenses
SPH
CYL
AX
ADD
OD
1.25
1
180
2.5
OS
1.25
1
155
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
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