New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 7/22/2025 11:34:00 AM
Cost:: 80
Service:: Frame+Lenses
prescribed by doctor:: OLD Rx
Notes:: AR

	SPH	CYL	AX	ADD
OD	-4.5
OS	-4.5	-0.75	80

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS