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ABVI address
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Client address
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Phone
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Other contact
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County
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Stand magnifier
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Cost
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Date returned
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Purchased?
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Hand magnifier
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Cost
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|
Date returned
|
Purchased?
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Pocket magnifier
|
Cost
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|
Date returned
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Purchased?
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Pocket magnifier
|
Cost
|
|
Date returned
|
Purchased?
|
|
Telescope
|
Cost
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|
Date returned
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Purchased?
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|
Prismatic glasses
|
Cost
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Date returned
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Purchased?
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Lighting/lamps
|
Cost
|
|
Date returned
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Purchased?
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Sunglasses
|
Cost
|
|
Date returned
|
Purchased?
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|
Sunglasses
|
Cost
|
|
Date returned
|
Purchased?
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|
Other low vision items
|
Cost
|
|
Date returned
|
Purchased?
|
|
Other low vision items
|
Cost
|
|
Date returned
|
Purchased?
|
|
Other low vision items
|
Cost
|
|
Date returned
|
Purchased?
|
|
Deposit paid at time of clinic
|
Amount of deposit
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|
Please bill
|
Amount that needs to be billed
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|
Items purchased
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Items purchased
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Total cost of items to purchase
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Amount of deposit paid at clinic
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Total of remaining balance
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Payment method
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Money collected by
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Date collected
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