New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/25/2025 5:32:00 PM
Cost:: 40
Service:: Frame + Lenses
prescribed by doctor:: OLD RX
Notes:: Metal Frame + AR

	SPH	CYL	AX	ADD
OD	-2.75	-0.25	80
OS	0	-1.25	180

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS