New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
8/28/2025 3:29:00 PM
Cost:
Service:
Frame + Lenses
prescribed by doctor:
old rx
Notes:
AR 1.61
SPH
CYL
AX
ADD
OD
1.75
-2
95
OS
1.75
-3
85
Date of visit:
12/30/2025 12:42:00 PM
Cost:
40
Service:
Frame + Lenses
prescribed by doctor:
Luna
Notes:
AR for Near
SPH
CYL
AX
ADD
OD
0.5
-1.75
105
1.5
OS
0.5
-3
90
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
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