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  • The Divine Mercy Polyclinic

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    This document is a statement of account from The Divine Mercy Polyclinic & Diagnostic Center providing a breakdown of fees for a patient's hospital stay. It lists fees for room accommodation, medicine, operating room, laboratory exams, medical gases, and other miscellaneous expenses under services. It also lists fees for the attending physician, surgeon, anesthesiologist, ultrasound, pathologist, and other professional services. The total fees, deposits, and balance owed are provided.

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    This document is a statement of account from The Divine Mercy Polyclinic & Diagnostic Center providing a breakdown of fees for a patient's hospital stay. It lists fees for room accommodation, medicine, operating room, laboratory exams, medical gases, and other miscellaneous expenses under services. It also lists fees for the attending physician, surgeon, anesthesiologist, ultrasound, pathologist, and other professional services. The total fees, deposits, and balance owed are provided.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    58 views1 page

    The Divine Mercy Polyclinic

    Uploaded by

    Angel
    This document is a statement of account from The Divine Mercy Polyclinic & Diagnostic Center providing a breakdown of fees for a patient's hospital stay. It lists fees for room accommodation, medicine, operating room, laboratory exams, medical gases, and other miscellaneous expenses under services. It also lists fees for the attending physician, surgeon, anesthesiologist, ultrasound, pathologist, and other professional services. The total fees, deposits, and balance owed are provided.

    Copyright:

    © All Rights Reserved
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    of 1

    THE DIVINE MERCY POLYCLINIC & DIAGNOSTIC CENTER

    Blk. 21, Lot 1, Phase 2, Area 1, Lapu-Lapu Avenue, Kaunlaran Village Navotas City

    Patient’s Name: __________________________________________ Age: ____ Sex: _____

    Address: ________________________________________________ Date: _____________

    Statement of Account

    A. SERVICES TOTAL

    Room Accomoation: ( days) ___________________


    Medicine:______________________________________
    Operating Room: _______________________________
    Laboratory Examination(s): _______________________
    Medical Gases: _________________________________
    Misc. Expenses: ________________________________

    TOTAL BILL P ___________________________

    B. PROFESSIONAL SERVICES:

    Attending Physician: _________________________


    Surgeon: ___________________________________
    Anesthesiologist: ____________________________
    Ultra Sound: ________________________________
    Pathologist: _________________________________
    Others : ____________________________________

    TOTAL PROFESSIONAL FEES P_____________________________

    TOTAL FEES (A & B) P _____________________________

    DEPOSITS P _____________________________

    BALANCE P _____________________________

    _____________________________
    Cashier

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