New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
3/26/2024 12:12:00 PM
Cost:
Service:
prescribed by doctor:
Old RX
Notes:
SPH
CYL
AX
ADD
OD
1.5
0.5
10
2.75
OS
1.75
0.5
170
2.75
Date of visit:
4/9/2024 1:38:00 PM
Cost:
0
Service:
Frame+Lenses
prescribed by doctor:
Old RX
Notes:
US Design Progressive+Fmc+Transtion
SPH
CYL
AX
ADD
OD
1.5
0.5
10
2.75
OS
1.75
0.5
170
2.75
New visit Information
Date of visit:
Cost in this visit:
type of service:
prescribed by doctor
Note:
SPH
CYL
AX
ADD
OD
OS
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