Invoice No:

Patient Name: An. Fakheera Rania Zuhdhi

Date of Birth: 03 Nov 2013
URN: 0000007200 EN: E0000005096

Invoice Details Episode Date: 26 Feb 2022 Time: 09:11

Attending Doctor: Felicia Caroline Dr.

Payor: TCH Employee Family (TCH2) / Jakarta Utara 14470

Invoice Date: 26 Feb 2022

Description Quantity Amount

Medicine

26 Feb 2022 SANmol Forte Syrup 250mg/5mL - 60mL 2 70,676.00

26 Feb 2022 IsopriNOSINE Syrup 250 mg/5 mL - 60 mL 3 406,056.75

Vitamins & Minerals

26 Feb 2022 Apialys Syrup 100 mL 1 45,375.00

Immunoserology 1

26 Feb 2022 SARS-COV2 Antigen (Rapid) [Felicia Caroline Dr.] 1 109,000.00

Consultation Fee Emergency Doctor

26 Feb 2022 ED GP Consultation Day [Felicia Caroline Dr.] 1 100,000.00

Registration Fee

26 Feb 2022 Registration Fee IGD 1 50,000.00

Total Amount 781,107.75

Total Nilai Tagihan Terbilang :

LIMA RATUS EMPAT RIBU DELAPAN RATUS DELAPAN PULUH ENAM RUPIAH DAN DUA PULUH Discount 276,221.55
SEN
Total Amount after Discount 504,886.20

Outstanding by TCH Employee Family (TCH2) / Jakarta Utara 14470 504,886.20

Print: 26 Feb 2022 11:24 by: Oktavianus Gregorius Print Loc: Cashier Pandemic

Pembayaran sah setelah kasir Tzu Chi Hospital memberikan cap lunas.

Pemeriksaan Laboratorium dan Radiologi yang telah dilaksanakan tidak dapat dibatalkan.
Patient
Barang dan jasa yang telah dibeli tidak dapat di kembalikan atau ditukar.

Pembayaran dapat dilakukan via transfer ke rekening: ...............................................................................................

Bank Artha Graha
An. Fakheera Rania Zuhdhi
Nomor rekening : 108 1200 188 a/n Yayasan Buddha Tzu Chi Medika Indonesia

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