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    Claim Stub - Optical Clinic

    Uploaded by

    Gabrielle Robles Santiago
    If your patient/client is purchasing something but you cannot give it immediately, you can ask for downpayment and give this claim stub. Indicate at the back of each stub the total purchase price, downpayment, and balance if there's any.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    Claim Stub - Optical Clinic

    Uploaded by

    Gabrielle Robles Santiago
    179 views2 pages
    If your patient/client is purchasing something but you cannot give it immediately, you can ask for downpayment and give this claim stub. Indicate at the back of each stub the total purchase price, downpayment, and balance if there's any.

    Original Title

    Claim stub - Optical Clinic

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    If your patient/client is purchasing something but you cannot give it immediately, you can ask for downpayment and give this claim stub. Indicate at the back of each stub the total purchase price, downpayment, and balance if there's any.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    179 views2 pages

    Claim Stub - Optical Clinic

    Uploaded by

    Gabrielle Robles Santiago
    If your patient/client is purchasing something but you cannot give it immediately, you can ask for downpayment and give this claim stub. Indicate at the back of each stub the total purchase price, downpayment, and balance if there's any.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 2

    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical

    n Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Claim Stub Claim Stub Claim Stub Claim Stub
    Rx #: Rx #: Rx #: Rx #:
    Date:_____________ Date:_____________ Date:_____________ Date:_____________
    Name:___________________ Name:___________________ Name:___________________ Name:___________________
    _ _ _ _
    Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
    _ _ _ _
    ________________________ ________________________ ________________________ ________________________
    ___ ___ ___ ___
    Due Due Due Due
    date:_________________ date:_________________ date:_________________ date:_________________
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison
    Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison
    Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
    Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison
    Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic

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