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BLK-Max Super Speciality Hospital

Pusa Road, New Delhi-110005
24-Hour Helpline: 011-3040 3040
Fax: +91-11-2575 2885, E: info@blkhospital.com

www.blkhospital.com
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Patient Name Ms. Simran. 20 years 18 days/ Female
Age/Sex
Date 28/07/2021 10:33AM Invoice No. :BLCS381429
Max Id BLKH.674361 Consultant's Name: Dr. Anil Kumar Murarka ( Plastic
Sponsor : (Cash)-Self Pay
Phone 9811109400

Investigation Advised: Consultation Start time 0'0Alergic to :N.ee Pain Score: 7/

Fall Risk Screening Nutrition Screening: Templc)
(If applicable)
VITAL SIGNS (As applicable)
ais
BP(mmHg): Pulse (per min): Height (emc): 5 Weight(k9)ie
Weight (k) S
Respiratory rate (per min):2ke Head Circumfrence(cme)in case of pediatric patients)

CHIEF COMPLAINTS: a l nt hom

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BRIEF HISTORY :N
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RELEVANT PAST MEDICAL HISTORY:
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FAMILY HISTORY:
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OBSTERICsMENSTRUAL HISTORY(if applicable:

Birth History/Immunization History(In case of pediatric patients if applicable):

www.
socIo-EcONOMIC &PSYCHOLOGICAL HISTORY: MR-
GENERAL EXAMINATION
Pallor Icterus Cyanosis Breathlessness

Level Of Consciousness: CenRueu, b i l e

Pedal Oedema Lymphadenopathy:

SYSTEMIC EXAMINATION(System applicable):

CVS

document. Please keep it s a f e and carry it in your next visit.

important
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FOLLOW UUP:

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next visit.
This is important document. Please keep it safe and carry it in your
 Dr. B L Kapur Memorial Hospital

BLK-MAX
Super Speciality Hospital
Pusa Road New Delhi Pin Code: 110005
Ph:30403040 E-mail: info@blkhospital.com
Bill of Supply *670674361*
Patient Name Ms. Simran Bill Date :28/07/2021 10:33AM
Age/Sex 20 years 18 days / Female
:14/65 GEETA COLONY Geeta ColonyNEW DELHI
Address
MaxId :BLKH.674361
Bill No BLCS381429
Referred By :Anil Kumar Murarka
Receipt No : BLRC340065
GSTN Bill Nc: 67210D000223236

GSTN No : 07AAATLO242R2ZE

SLNo. Services SAC Qty Base Tariff Piscount Net AmountTax Amt Bill Amoun
Price(Rs.)IPrice(Rs,) (Rs.) (Tax%)(Rs.)
Anil Kumar Murarka 999312
1800.00 1800.00 0.d0 1800.00 1800.00
| (Consultation )( Plastic
Surgeon (
Total 0.00 1800.00 1800.00

Paid by Patient 1800.00

Amount in Words Rupees one thousand eight hundred only collected from patient

Sum Of Rs. 1800.00 received with thanks from Ms. Simran

PaymentModels)
CC for Rs.1800.000(CC No. 0oxXxx2647)
Signature
Signature of Patient/Next of Kin
Vivek Kumar

Place of Supply :DELHI-(07)

Dr. B LKapur Memorial Hospital
Company Name
:AAATLO242R
PAN No.
 Dr. B L Kapur Memorial Hospital

aMAX Pusa Road New Delhi Pin Code: 110005

ef Speciality Hospital Ph:30403040 E-mail:info@blkhospital.com
Bill of Supply *670674361*
Patient Name :Ms. Simran .
Bill Date 28/07/2021 11:45AM
Age/Sex 20 years 18 days/ Female
Address 14/65 GEETACOLONY Geeta ColonyNEW DELHI
MaxId BLKH.674361

Bill No BLCS381709
Referred By Anil Kumar Murarka
Receipt No : BLRC340305
GSTN Bill Nc: 67210DO000223516

GSTN No 07AAATLO242R2ZE

sl.No. Services SAC QtyBase Tariff Discount Net AmounTax Amt Bill Amoun
Price(Rs.) Price(Rs.) (Rs.) Tax %) (Rs.)
1 SUTURING OF LARGE 999312 9500.00 9500.00 0.d0 9500.00 9500.00
LACERATED WOUND (B 24
- Dr. Anil Kumar Murarka
0
2 Dressing-Category B ( By | 999312 910.00 910.00 0.0 910.00 910.00 24
- Dr. Anil Kumar Murarka
24
Dressing Set ( By Dr. 470.00 470.00 0.d0 470.00 470.00
Anil Kumar Murarka)0_
Total 0.00 10880.00 10880.00

Paid by Patient 10880.00

Amount in Words: Rupeesten thousand eight hundred eighty only collected from patient
Sum Of Rs. 10880.00 received with thanks from Ms. Simran.

Payment Models)
CCfor Rs.10880.000(CC No. XXXXXKXx2647)

Signature of Patient/Next of Kin

Signature
Vivek Kumar

Place of Supply :DELHI-(07)

Company Name :Dr. BL Kapur Memorial Hospital

PAN No. :AAATLO242R

 Dr. B L Kapur Memorial Hospital

LK-MAX
Super Speciality Hospital
Pusa Road New Delhi Pin Code: 110005
Ph:30403040 E-mail:info@blkhospital.com
Bill of Supply
*670674361*
Patient Name :Ms.Simran.
Bill Date 28/07/2021 11:43AM
Age/Sex :07/10/2001 00:00:00/ Female
Address :14/65 GEETA COLONY Geeta ColonyNEW DELHI
MaxId BLKH.674361

Referred By Bill No BLCS381699

Anil Kumar Murarka
Receipt No : BLRC340297
GSTN Bill Nc: 67210D00223506
nt GSTN No :07AAATLO242R2ZE
Sex
rred

ess
SLNo. Services SAC Qty Base Tariff Discount Net AmounTax Amt Bill Amoun
phor PriceRs.)| Price(Rs.) (Rs.) I(Tax %) (Rs.)
e(Co
1 Consumption during 999312 1 0.00 981.24 981.24
providing medical services
AUG 981.24
TABL Total 0.00 981.24
DICL
NEOS
SKIN
Paid by Patient 981.24

Amount in Words: Rupees nine hundred eighty-one only collected from patient
Sum Of Rs. 981.24 received with thanks from Ms. imran

Amou

talTa Payment Models)

CC for Rs.981.240(CC No. XX0XxXKx2647, Card Name: A Advantage)
lance
ceive Signature
scount Signature of Patient/Next of Kin
No. Vivek Kumar
luding
Place of Supply :DELHI-( 07)
ods Company Name :Dr. BLKapur Memorial Hospital
ntei PAN No. AAATLO242R
hoi

Run D
 Dr. BL Kapur
Memorial tHospital
NBLK MAX
Super Specality Hosptal
Pusa Road New Delhi Pin Code: 110005
Ph:30403040 E-mail : info@blkhospital.com
Dr. BL Kapur Memorial Hospital,Pusa Road, New Delhi-110005

Tax Invoice
Patient Name Ms. Simran Date 28-Jul-2021 12 0/ prm
Age/Sex 19Year(s)I Female GST Bill No
Referred By
6721PAO000041602
Arun Antony Pusa Road.New Delhi Maxld BLKH 674361
Invoice/Receipt No 71823/71635
Address 14/65 GEETA COLONY Geeta Colony NEW DELHI, Pharma Bill No 71823
Geeta Colony, DELHI, 110031, India
GSTIN No 07AAATL0242R27E
Telephone 9811109400
PAN No ATLO242R
State Code) DELHI (07)

SI Particulars HSN CGST SGST

No
Qty Batch No Expiry Price Amount Discount
Code % Amt
before Disc. Collected
IAUGMENTIN 625 MG 300410 6.00 6.00 inc GST
TABLET IX10* 10 MC397 Oct-2022 18.01 180.10 0.00 201.71
2 DICLOMOL TABLETS 300490 6.00 6.00 10 PDO181 Mar-2024 6.92 69..20 0.00 77.50
3 NEOSPORIN 30GM*
300420 6.00 6.00 1FE6U
SKIN OlNT. TUBE* Aug-2022 142.10 142.10 000 159.15

12%%
Total

Total 391.40
391. 40 48 36
Discount 0.00

Net Amount 391.40 391.40

#TotalTax 46.98 97

Amount Collected: 438.38 438.36

Balance 0.00
Received Sum of Rs. 438.36 By Card, Card No. XXXXXXXXXXXX2647
Your Saving: 0.00
Discount Reason
DL. No.
20-129596, 21-129597 Pharmacist
#Including CGST @6.00%: Rs. 23.49,SGST @6.00%%: Rs. 23.49,UTGST @0.00%: R_. 0.00,CESS @0.00%: Rs. 0.00

Goods once sold cannot be taken back. Error in billing, If any, is an oversight and is
unintentional
For home delivery c o n t a c t a t +91-9599485855 * conditions apply

97 T

Run Date: 28-Jul-2021 12:07 pm Page I of