[Hospital Name]

[HospitalAddr1]
[HospitalAddr2]
[HospitalAddr3]
[HospitalAddr4]
[Heading]
             
Patient ID :[PTNO] Patient Name :[PTNAME]    
Address :[ADDRESS] Sex/Age :[SEX]/[AGE]    
Mobile :[MOBILE] Doctor Name :[DSALU][MEDICALOFFICER]  
       
Right Eye   Left Eye
SPH CYL AXIS VISION SPH CYL AXIS VISION
[SPHDVR] [CYLDVR] [AXISDVR] [VISIONDVR] Distant Vision [SPHDVL] [CYLDVL] [AXISDVL] [VISIONDVL]
[SPHNVR] [CYLNVR] [AXISNVR] [VISIONNVR] Near Vision [SPHNVL] [CYLNVL] [AXISNVL] [VISIONNVL]
Increasing Factor :[INCFACT]
Bifocals :[BIFOCALS]
IPD :[IPD]
Tint :[TINT]
Advice :[ADVICE]
  [DSALU][MEDICALOFFICER]
[DEPARTMENT]
                         
                           Printed Date : [PrintDate]

 User:  [UserName]