New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:
Cost:: 25
Service:
prescribed by doctor:
Notes:: toric contact lenses

	SPH	CYL	AX	ADD
OD	-1	-2.25	20
OS	-3.5	-2.25	150

Date of visit:: 11/11/2025 4:39:00 PM
Cost:: 30
Service:: Contact Lenses
prescribed by doctor:: OLD RX
Notes:: toric polyview

	SPH	CYL	AX	ADD
OD	-1	-2.25	20
OS	-3.5	-2.25	150

Date of visit:: 10/14/2025 4:52:00 PM
Cost:: 30
Service:: Contact Lenses
prescribed by doctor:
Notes:: toric polyview +solution

	SPH	CYL	AX	ADD
OD	-1	-2.25	20
OS	-3.5	-2.25	150

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS