New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 7/4/2025 1:35:00 PM
Cost:: 20
Service:: Change Lenses
prescribed by doctor:: Old RX
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	0.5	-3	95
OS	0.5	-3	85

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS