|
Patients name and DOS
|
|
|
Brand
|
Brand comment
|
|
Sph. OD
|
Cyl OD
|
|
Axis OD
|
Sph. OD
• • •
|
|
ADD OD
|
Color(s)
|
|
Sph. OS
|
Cyl OS
|
|
Axis OS
|
Sphere OS
• • •
|
|
ADD OS
|
Color(s)
|
|
Total charges
|
Insurance name and payment
|
|
Patient responsibility
|
Balance due
|
