New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 5/10/2024 6:03:00 PM
Cost:: 120
Service:: Rimless
prescribed by doctor:: Old Rx
Notes:

	SPH	CYL	AX	ADD
OD	-2	-0.5	130
OS	-2	-0.75	30

Date of visit:: 9/2/2024 7:07:00 PM
Cost:: 200
Service:: Frame+Lenses
prescribed by doctor:: Old RX
Notes:: rimless

	SPH	CYL	AX	ADD
OD	-2	-0.5	130
OS	-2	-0.75	30

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS