New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 10/14/2023 12:40:00 PM
Cost:: 25
Service:: Contact Lenses Polyview
prescribed by doctor:: Dr. Jamal Bleik
Notes:: TORIC CONTACT LENSES

	SPH	CYL	AX	ADD
OD	-3.5	1	100
OS	-3	0.75	90

Date of visit:: 3/14/2024 12:42:00 PM
Cost:: 30
Service:: Contact Lenses
prescribed by doctor:: Dr. Jamal Bleik
Notes:: TORIC CONTACT LENSES

	SPH	CYL	AX	ADD
OD	-3.5	1	100
OS	-3	0.75	90

Date of visit:: 6/11/2024 3:26:00 PM
Cost:: 25
Service:: Toric Polyview
prescribed by doctor:: Dr. Jamal Bleik
Notes:: Polyview

	SPH	CYL	AX	ADD
OD	-3.5	1	100
OS	-3	0.75	90

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS