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Client address
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Client phone
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Expiration Date
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Special Recomendations
• • •
|
Comments
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Second Rx
|
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OD
|
OD acuity with rx
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OD Prism
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OS
|
OS acuity with rx
|
|
OS Prism
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Add Power
• • •
|
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Special Recomendations
• • •
|
Comments
|
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Distance PD
|
Near PD
|
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Comments
|
|
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Signature:
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Physician
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Certified LV Specialist
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NPI number
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Office phone
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Return Address
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