New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:
Cost:: 200
Service:: Frame + Lenses
prescribed by doctor:: Dr. Ali Harb
Notes:: progressive lenses FMC infinity US Design, she lives in USA,( Dr. hussein reduces o.25 from cyl.)

	SPH	CYL	AX	ADD
OD	2	-0.75	20	1.5
OS	2.5	-1	145	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