New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/26/2025 5:42:00 PM
Cost:: 50
Service:: Frame + Lenses
prescribed by doctor:: Dr. Hassan Sallam
Notes:: Plastic Frame + AR Lenses

	SPH	CYL	AX	ADD
OD	1.5	-2.25	95
OS	1.5	-2.25	90

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS