New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 8/19/2025 3:38:00 PM
Cost:: 35
Service:: Change Lenses
prescribed by doctor:: old rx
Notes:: Antiblue

	SPH	CYL	AX	ADD
OD	-1.5
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