New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/9/2024 2:42:00 PM
Cost:: 50
Service:: Frame + Lenses
prescribed by doctor:: Aya
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	0.5	-1.25	25
OS	0.5	-1	160

Date of visit:: 9/30/2025 3:30:00 PM
Cost:: 70
Service:: Frame + Lenses
prescribed by doctor:: OLD RX
Notes:: Airlite + AR Transition W9

	SPH	CYL	AX	ADD
OD	0.5	-1.25	25
OS	0.5	-1	160

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS