Invoice
Invoice No: #745664
Date: 22/03/2023
Invoice To:
Alex Farnandes
450 E 96th St, Indianapolis,
WRHX+8Q IN 46240,
United States
450 E 96th St, Indianapolis,
WRHX+8Q IN 46240,
United States
Invoise Hospital:
4510 E 96th St, Indianapolis,
IN 46240, Inoba, Austona
info@Invoisehospital.com
+153 6547 3698
IN 46240, Inoba, Austona
info@Invoisehospital.com
+153 6547 3698
Patient Information:
| Patiend Name: | Alex Farnandes | Patient ID: | 123456789 |
|---|---|---|---|
| Patient Age: | 35 Years | Service: | Blood Test |
| Due Date: | 27/07/2022 | Insurence Billed: | WPS |
| Address: | 4 Balmy Beach Road, Owen Sound, Ontario, Canada | ||
| Details | Price | Tax | Amount |
|---|---|---|---|
| Blood Test | $250.00 | 10% | $275.00 |
| Test Kit | $15.00 | 2% | $15.30 |
| Consultant Surgeon Fee | $20.00 | 0% | $20.00 |
| Medical Hospital Supply | $25.00 | 0% | $25.00 |
| Nursing Service Charge | $30.00 | 0% | $330.00 |
| Total Amount: | $365.30 | ||
Payment Info:
Credit Card No: 2456**********
A/C Name: Alex Farnandes
| Paid: | $545.00 |
|---|---|
| Balance Due: | $00.00 |
Invoise Inc:
12th Floor, Plot No.5, IFIC Bank, Gausin Rod, Suite 250-20, Franchisco USA 2022.
NOTE: This is computer generated receipt and does not require physical signature.