New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 7/14/2025 11:57:00 AM
Cost:: 100
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: Zenni Antiblue lenses

	SPH	CYL	AX	ADD
OD	-3.5	-0.5	15
OS	-1.75	-1.5	18

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS