New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
6/13/2025 11:23:00 AM
Cost:
90
Service:
Frame + Lenses
prescribed by doctor:
Old RX
Notes:
AR 1.61, LEVIS
SPH
CYL
AX
ADD
OD
3.25
0.75
145
OS
4
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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