New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
12/18/2025 12:14:00 PM
Cost:
80
Service:
Frame + Lenses
prescribed by doctor:
Dr. Jamal Bleik
Notes:
Trench Frame + AR Transition W9
SPH
CYL
AX
ADD
OD
-1.75
1.5
140
OS
-2.5
2
70
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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