Vision Plus of Ballard

5406 Leary Ave NW

Seattle, WA 981074068
Phone: (206) 784-0700
Fax: (206) 706-8822

Contact Lens Rx

Patient: Baker, Carson Rx Date: 28-Oct-2022

1511 NW 52nd St Expiration: 28-Oct-2024
Seattle, WA 98107
(425)308-9042(C) (425)308-9042(H)

Sphere Cylinder Axis Add Prism Base Curve Diameter Multifocal

OD: -2.75 D.S. 000 8.70 14.0
OS: -1.25 D.S. 000 8.70 14.0

Manufacturer Lens Color Material

OD: Alcon Dailies Aqua Comfort Plus Clear
30pk
OS: Alcon Dailies Aqua Comfort Plus Clear
30pk
Replacement Schedule: One Day
Notes: Order trials and dispense, pt to call to finalize if happy

Phoebe Gayoso, O.D.

Pursuant 16 CFR § 315.5 (Prescriber verification), we require a signature and date of the patient or Guardian when dispensing
contact lens prescriptions. We also require explicit permission to share your prescription with 3rd party providers or resellers
when responding to prescription verification requests.
Please sign and date below indicating you have received this prescription.

May we respond to 3rd party providers and

resellers with a copy of your current prescription?
Signature Date
Yes

Printed Name
No

Printed: Nov-23-2022 10:01 AM