DAYOS – PASCUAL MEDICAL CLINIC

Rang-ayan, Roxas, Isabela

Name of Patient:________________________________________ Bill# :_____________________
Address : ______________________________________________
Ages:_____________________
Attending Physician:_____________________________________ Bldg/Room#:_______________
Admitting Diagnosis:_____________________________________ Date Admitted: _____________
Final Diagnosis: _________________________________________ Date Discharged:____________
STATEMENT OF ACCOUNT
Hospital Charges Actual Senior Phil Health
Charges Citizen Benefits Patient

Drugs & Medicine        

Laboratory        
X-Ray        
Oxygen        
EGC        
Medical Supplies        
Surgical Supplies        
         
         
Delivery Fee/D & C Fee/OR Fee        
Ward Procedure        
Admission Kit        
Room & Board        
Professional Fee        
Anesthesiologist Fee        
Miscallaneous Fee        
Total        

TOTAL BILL _______________________

AMOUNT PAID ____________________
O.R. NUMBER _____________________
DATE PAID ________________________ _____________________________
Signature over Printed Name
Prepared By:
Contact No: ___________________
___________________________________