New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 12/11/2023 5:33:00 PM
Cost:: 90
Service:: Frame + Lenses
prescribed by doctor:: Aya
Notes:: Airlite Plano

	SPH	CYL	AX	ADD
OD
OS

Date of visit:: 7/15/2024 5:34:00 PM
Cost:: 100
Service:: Frame+Lenses
prescribed by doctor:: Old RX
Notes:: AR + Transition PLANO

	SPH	CYL	AX	ADD
OD
OS

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS