New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/1/2024 1:36:00 PM
Cost:: 75
Service:: Frame + Lenses
prescribed by doctor:: Old Rx
Notes:: AR + Transition

	SPH	CYL	AX	ADD
OD	-3	-2	180
OS	-2.75	-2	180

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS