New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 6/4/2024 4:50:00 PM
Cost:: 14
Service:: Clear 55 contact lenses
prescribed by doctor:: Old Rx
Notes:: + NEO Solution

	SPH	CYL	AX	ADD
OD	-2.5
OS	-2.5

Date of visit:: 7/16/2024 5:52:00 PM
Cost:: 11
Service:: CLEAR 55
prescribed by doctor:: Old RX
Notes:: Without Solution

	SPH	CYL	AX	ADD
OD	-2.5
OS	-2.5

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS