New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 6/19/2024 2:37:00 PM
Cost:: 8
Service:: Polyview CL
prescribed by doctor:: Aya
Notes:

	SPH	CYL	AX	ADD
OD	-5.75
OS	-5.75

Date of visit:: 4/5/2025 3:27:00 PM
Cost:: 11
Service:: Contact Lenses
prescribed by doctor:: Old Rx
Notes:: Polyview + Solution

	SPH	CYL	AX	ADD
OD	-5.5
OS	-5.5

Date of visit:: 8/21/2025 12:30:00 PM
Cost:: 8
Service:: Contact Lenses
prescribed by doctor:: OLD Rx
Notes:: poly view

	SPH	CYL	AX	ADD
OD	-5.75
OS	-5.75

Date of visit:: 5/7/2026 10:36:00 AM
Cost:: 10
Service:: Polyview
prescribed by doctor:: old rx
Notes:

	SPH	CYL	AX	ADD
OD	-4.25	-0.5	25
OS	-4.75	-0.75	160

Date of visit:: 10/14/2025 5:10:00 PM
Cost:: 8
Service:: Contact Lenses
prescribed by doctor:: Old RX
Notes:: polyview

	SPH	CYL	AX	ADD
OD	-5.75
OS	-5.75

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS