New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/20/2025 4:48:00 PM
Cost:: 5
Service:: Eye Exam
prescribed by doctor:: Luna
Notes:

	SPH	CYL	AX	ADD
OD	-0.75	-0.75	100
OS	0	-0.5	65

Date of visit:: 1/16/2026 5:17:00 PM
Cost:: 50
Service:: Frame+Lenses
prescribed by doctor:: luna
Notes:: AR

	SPH	CYL	AX	ADD
OD	-0.75	-0.75	100
OS	0	-0.5	65

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS