New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:
Cost:: 17
Service:
prescribed by doctor:
Notes:: AR

	SPH	CYL	AX	ADD
OD	-1.5
OS	-1.75

Date of visit:: 9/16/2024 5:30:00 PM
Cost:: 16
Service:: Contact Lenses
prescribed by doctor:: Old Rx
Notes:: Clear 55

	SPH	CYL	AX	ADD
OD	-1.5
OS	-1.75

Date of visit:: 12/7/2024 3:56:00 PM
Cost:: 11
Service:: Contact Lenses
prescribed by doctor:: Old Rx
Notes:: Clear 55 + Solution

	SPH	CYL	AX	ADD
OD	-1.5
OS	-1.75

Date of visit:: 3/14/2025 3:16:00 PM
Cost:: 15
Service:: Contact Lenses
prescribed by doctor:: OLD Rx
Notes:: Clear 55 + Versace Solution

	SPH	CYL	AX	ADD
OD	-1.5
OS	-1.75

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS