New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
10/1/2025 3:14:00 PM
Cost:
60
Service:
Frame + Lenses
prescribed by doctor:
Nancy
Notes:
Airlite + AR lenses for NEAR ONLY!
SPH
CYL
AX
ADD
OD
0.5
-0.5
85
2.25
OS
0.75
-0.75
80
2.25
Date of visit:
12/27/2025 12:50:00 PM
Cost:
100
Service:
Frame + Lenses
prescribed by doctor:
OLD Rx
Notes:
Guess Frame + AR for near only
SPH
CYL
AX
ADD
OD
0.5
-0.5
85
2.25
OS
0.75
-0.75
80
2.25
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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