New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 7/26/2024 6:21:00 PM
Cost:: 75
Service:: Frame + Lenses
prescribed by doctor:: Aya + OLD RX
Notes:: Airlite + AR Lenses +Transition Single Vision 1.61

	SPH	CYL	AX	ADD
OD	5			1.25
OS	5			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