equipment operator
Resume:
Phone:
Fax:
Date of EG Exam:
Name: Michael Wright
Halls, TN 38040
TN-Dyersburg
Dyersburg, TN 380241927
Patient Eyeglass Prescription Information
Sphere Cyl Axis Add Prism / Dir Prism / Dir
Right (OD)
Left (OS)
I have examined your eyes in accordance with current regulations. Prescription Expiration Date:
Eyeglass Rx Type
Doctor Signature Doctor Name
06/12/2024
Leslie Sides
Multi-Focal
+1.00
+1.25
-0.25
-0.50
135
095
2.50
2.50
Slab off Balanced
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