New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/21/2026 5:54:00 PM
Cost:: 70
Service:: Frame + Lenses
prescribed by doctor:: Old RX
Notes:: AR degrees are patient responsibility

	SPH	CYL	AX	ADD
OD	-3.25
OS	-1.75

Date of visit:: 1/24/2026 4:14:00 PM
Cost:: 25
Service:: change lenses
prescribed by doctor:: OLD rX
Notes:: AR Lenses, NOW ARE THE CORRECT DEGREES

	SPH	CYL	AX	ADD
OD	0	-3.5	168
OS	0	-1.75	15

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS