New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 1/31/2026 5:45:00 PM
Cost:: 250
Service:: Frame + Lenses
prescribed by doctor:: dr. Ali Alhaj
Notes:: Progressive infinity AR +MONTAGE

	SPH	CYL	AX	ADD
OD	1.25	1.25	180	2.5
OS	1.25	1.25	180	2.5

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS