New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 8/16/2025 1:06:00 PM
Cost:: 150
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	-4.5	-0.25	170
OS	-5	-0.5	20

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS