CANDON HOSPITAL

Tel. No(s): 742-6113 / 742-6093

Patient Name: BRAGADO, ANNALISA P.

Hospitalization Plan: None
Patient Address: Santiago, Ilocos Sur
Registry No.: 39915
Age:37Y7M20D
Registry Date: 12/19/2018
Discharge: 12/23/2018

Detailed Patient Statement of Account

Description QTY Unit Price Amount

Pharmacy

Acidan 500mg Cap 75 15.34 1,150.5

Bandax 500mg Cap 75 21.60 1,620
Xylocaine 2% Carp 3 79.40 238.2
Sub Total>>>> 3,008.7
Supplies
Er Os 1 500 500
Surgical Blade #11 1 300 300
Syringe w/Needle 3cc 1 300 300
Sub Total>>>> 1,100

Professional Fee:
FIGUERO C, EMILIA TAQUEB 6,500
Sub Total>>>> 6,500

Grand Total>> 10,608.7

Note: This SOA also serves as your invoice