New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 10/10/2025 8:22:00 PM
Cost:: 5
Service:: Refraction
prescribed by doctor:: Luna
Notes:: Repeat Eye Exam if he comes back

	SPH	CYL	AX	ADD
OD	2	-0.5	80
OS	1.75		180

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS