New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 3/16/2024 1:22:00 PM
Cost:: 60
Service:: Frame + Lenses + Change lenses
prescribed by doctor:: Aya
Notes:: AntiBlue Lenses + G15 Lenses

	SPH	CYL	AX	ADD
OD	-3.5	-1.25	170
OS	-3.5	-1.25	180

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS