New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 6/13/2024 4:46:00 PM
Cost:: 109
Service:: Frame + Lenses + Blink + Clear 55 + Eyedia
prescribed by doctor:: Aya
Notes:: 14$ + 11$ + 4$ + 80$

	SPH	CYL	AX	ADD
OD	-1.25
OS	-1.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS