New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 7/16/2024 4:51:00 PM
Cost:: 30
Service:: Change Lenses
prescribed by doctor:: OLD RX
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	-2.25
OS	-1

Date of visit:: 5/19/2025 1:54:00 PM
Cost:: 20
Service:: change lenses
prescribed by doctor:: Old RX
Notes:: AR

	SPH	CYL	AX	ADD
OD	-2.25
OS	-1.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS