New Visit
patient
Patient Name:
Phone number:
PD of patient:
visits:
Date of visit:
6/20/2024 6:30:00 PM
Cost:
25
Service:
Toric PolyView
prescribed by doctor:
Dr. Jamal Bleik
Notes:
Seeing Double Vision
SPH
CYL
AX
ADD
OD
4
1.25
180
OS
2.25
1
170
New visit Information
Date of visit:
Cost in this visit:
type of service:
prescribed by doctor
Note:
SPH
CYL
AX
ADD
OD
OS
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