New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 9/23/2025 3:31:00 PM
Cost:: 25
Service:: Change Lenses
prescribed by doctor:: Old Rx
Notes:: AR LENSES

	SPH	CYL	AX	ADD
OD	-1
OS	-1.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS