New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 8/8/2025 2:45:00 PM
Cost:: 290
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: 2pairs of lenses 1.61

	SPH	CYL	AX	ADD
OD	4	-2	175
OS	4.5	-2.25	163

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS