New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/29/2025 1:28:00 PM
Cost:: 5
Service:: Eye Exam
prescribed by doctor:: Luna
Notes:

	SPH	CYL	AX	ADD
OD		-1.75	5
OS		-1.75	175

Date of visit:: 12/29/2025 5:38:00 PM
Cost:: 60
Service:: Frame + Lenses
prescribed by doctor:: Luna
Notes:: Bulget + AR

	SPH	CYL	AX	ADD
OD		-1.75	5
OS		-1.75	175

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS