New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 7/1/2025 11:29:00 AM
Cost:: 100
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: 2 frames airlite

	SPH	CYL	AX	ADD
OD	-1.5	-0.5	3
OS	-1.5	-0.25	5

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS