New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/3/2024 6:53:00 PM
Cost:: 30
Service:: Biofinity Contact Lenses
prescribed by doctor:: Old Rx
Notes:

	SPH	CYL	AX	ADD
OD	-1.25	-0.75	130
OS	-0.75	-0.75	30

Date of visit:: 5/4/2024 6:54:00 PM
Cost:: 25
Service:: Bella Jade Green With Degrees
prescribed by doctor:: Old Rx
Notes:: Spherical Equivalence

	SPH	CYL	AX	ADD
OD	-1.5
OS	-1.25

Date of visit:: 7/27/2026 6:12:00 PM
Cost:: 35
Service:: bella contact lenses
prescribed by doctor:
Notes:: Silver race lenses

	SPH	CYL	AX	ADD
OD	-2.5	1.25	40
OS	-1.75	0.75	130

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS