New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 6/26/2024 4:32:00 PM
Cost:: 75
Service:: Frame + Lenses + Change Lenses
prescribed by doctor:: Dr. Mohammad Assaf
Notes:: New Frame = 60$ Change Lenses = 15$

	SPH	CYL	AX	ADD
OD	0.25
OS		-0.75	120

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS