New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 10/10/2025 1:35:00 PM
Cost:: 230
Service:: Frame + Lenses
prescribed by doctor:: Dr. prescription
Notes:: progressive standard pravious AR +MONTAGE, THE patient responsibility to add 0.25 for both near and far

	SPH	CYL	AX	ADD
OD	1.25	-1.25	165	3
OS	0.25	-0.75	175	3

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS