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

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS