New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 9/15/2025 2:32:00 PM
Cost:: 150
Service:: Change Lenses +Frame +lenses
prescribed by doctor:: Old RX
Notes:: Transition AR W9+ AR

	SPH	CYL	AX	ADD
OD	4	-1.25	150
OS	2	-0.75	70

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS