New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/5/2023 10:29:00 AM
Cost:: 7
Service:: Contact Lenses Polyview
prescribed by doctor:
Notes:: One Pair

	SPH	CYL	AX	ADD
OD	-1.75
OS	-1.25

Date of visit:: 3/25/2025 5:14:00 PM
Cost:: 10
Service:: Contact Lenses
prescribed by doctor:: OLD Rx
Notes:: Clear 55

	SPH	CYL	AX	ADD
OD	-2
OS	-1.5

Date of visit:: 3/25/2025 5:14:00 PM
Cost:: 10
Service:: Contact Lenses
prescribed by doctor:: OLD Rx
Notes:: Clear 55

	SPH	CYL	AX	ADD
OD	-2
OS	-1.5

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS