VAT Registration No : 310152224710003 ‫ﺭﻗﻢ ﺗﺴﺠﻴﻞ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬ Treating Doctor : Dr HEBAH YOUNES ‫ﺍﻟﻄﺒﻴﺐ ﺍﻟﻤﻌﺎﻟﺞ‬

Address : ‫ ﺍﻷﺣﺴﺎء‬، ‫ ﺷﺎﺭﻉ ﺍﻟﻈﻬﺮﺍﻥ‬- ‫ﺣﻲ ﺍﻟﻴﺤﻴﻰ ﻓﻲ ﺍﻟﻤﺒﺮﺯ‬

‫ﻓﺎﺗﻮﺭﺓ ﺿﺮﻳﺒﻴﺔ‬

MRN : HAS20000077411 : ‫ﺭﻗﻢ ﺍﻟﺴﺠﻞ ﺍﻟﻄﺒﻲ‬ Bill No: INV-O-HAS1-23003913 : ‫ﺭﻗﻢ ﺍﻟﻔﺎﺗﻮﺭﺓ‬

Patient Name: Mr MOHAMMED :‫ﺳﻢ ﺍﻟﻤﺮﻳﺾ‬ Bill Date: Feb 5, 2023 11:43 AM : ‫ﺗﺎﺭﻳﺦ ﺍﻟﻔﺎﺗﻮﺭﺓ‬
ARAFA ABDULRMAN Coordinator : Dr HEBAH YOUNES ‫ﺍﻟﻤﻨﺴﻖ‬
Nationality: EGYPTIAN : ‫ﺟﻨﺴﻴﺔ‬ Al Etihad Coop Ins Co VATNO-
Insurance Name :
Identification No: 2476825068 :‫ ﺍﻻﻗﺎﻣﺔ‬/ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ‬ 300057331400003

: ‫ﻋﺪﺩ ﺍﻟﺰﻳﺎﺭﺍﺕ‬ City : Postal Code-

Visit No: OP-007
: ‫ ﺍﻟﺠﻨﺲ‬/ ‫ﺍﻟﻌﻤﺮ‬ Policy No : TU/47/MED/2022/00229
Age/Sex: 39Yrs/MALE
Policy Name : AL-KIFAH NATIONAL AC
Membership No.: 6007549935

Particulars Limit / CPT / Qty Gross Discount Sub Deduct. Net Amount Patient Company Deduct Net Amt
‫ﻭﺻﻒ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﻄﺒﻴﺔ‬ Install Tooth No ‫ﺍﻟﻌﺪﺩ‬ Amt Amt Total Amount ‫ﺻﺎﻓﻰ ﺍﻟﻘﻴﻤﺔ‬ VAT Vat With With
‫ﺭﻗﻢ‬/‫ﻛﻮﺩ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﺟﻤﺎﻟﻰ ﺍﻟﻘﻴﻤﺔ‬ ‫ﺍﻟﺨﺼﻢ‬ ‫ﺍﻻﺟﻤﺎﻟﻰ ﺑﻌﺪ‬ ‫ﻗﻴﻤﺔ ﺍﻟﺘﺤﻤﻞ‬ ‫ﺿﺮﻳﺒﺔ‬ ‫ﺿﺮﻳﺒﺔ ﺷﺮﻛﺔ‬ Patient Company
‫ﺍﻟﺴﻦ‬ ‫ﺍﻟﺨﺼﻢ‬ ‫ﺍﻟﻤﺮﺍﺟﻊ‬ ‫ﺍﻟﺘﺎﻣﻴﻦ‬ VAT VAT
‫ﻗﻴﻤﺔ ﺍﻟﺘﺤﻤﻞ‬ ‫ﺍﻟﺼﺎﻓﻰ ﺑﺎﻟﻀﺮﻳﺒﺔ‬
‫ﺑﺎﻟﻀﺮﻳﺒﺔ‬

Consultation

Checkup by General 101/0 1 25.00 0.00 25.00 5.00 20.00 0.75 3.00 5.75 23.00
Practitioner | Dr HEBAH
YOUNES

Sub Total: 25.00 0.00 25.00 5.00 20.00 0.75 5.75 23.00

DENTAL

Infected RCT + Filling 417/26 1 800.00 0.00 800.00 54.00 746.00 8.10 111.90 62.10 857.90

Abscess Drainge 604/26 1 100.00 0.00 100.00 0.00 100.00 0.00 15.00 0.00 115.00

Sub Total: 900.00 0.00 900.00 54.00 846.00 8.10 62.10 972.90

Add : VAT VAT Amount

VAT(Applicable on Amount 925) 138.75

‫ﺍﺟﻤﺎﻟﻰ ﺍﻟﻘﻴﻤﺔ‬ Gross Total : 925.00
‫ ﺍﻟﺨﺼﻢ‬Discount : 0.00
:
‫ ﺿﺮﻳﺒﺔ ﺍﻟﺸﺮﻛﺔ‬VAT (15%) 129.90
:
‫ﺍﻻﺟﻤﺎﻟﻰ ﺑﻌﺪ ﺍﻟﺨﺼﻢ ﺑﺎﻟﻀﺮﻳﺒﺔ‬ Total Amount includingVAT 1,063.75
‫ ﺍﻟﺘﺤﻤﻞ ﺍﻟﻤﺪﻓﻮﻉ ﻧﻘﺪﺍ‬Patient Net Amount
: 67.85
Patient Collected Amount : 67.85
Patient Balance Amount : 0.00
‫ ﺍﻟﺼﺎﻓﻰ ﺑﺎﻟﻀﺮﻳﺒﺔ‬Insurance Net Amount : 995.90

‫ ﻣﻦ ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﺪﻓﻮﻉ ﻣﻘﺎﺑﻞ ﻣﺼﺎﺭﻳﻒ ﻣﺎﻟﻴﺔ ﻭﺍﺩﺍﺭﻳﺔ " ﻭﻓﻲ ﺟﻤﻴﻊ‬%10 ‫ﺿﻴﻮﻓﻨﺎ ﺍﻟﻜﺮﺍﻡ ﻧﻮﺩ ﺇﻋﻼﻣﻜﻢ ﺑﺄﻧﻪ ﻓﻲ ﺣﺎﻝ ﻋﺪﻡ ﺍﻟﺤﺼﻮﻝ ﻋﻠﻰ ﺃﻱ ﺧﺪﻣﺔ ﻳﺤﻖ ﻟﻠﻤﺮﺍﺟﻊ ﺍﺳﺘﺮﺩﺍﺩ ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﺪﻓﻮﻉ ﺧﻼﻝ ﺳﺒﻌﺔ ﺍﻳﺎﻡ ﻣﻦ ﺗﺎﺭﻳﺦ ﺍﻟﺪﻓﻊ ﺃﻣﺎ ﺑﻌﺪ ﻣﺮﻭﺭ ﺃﻛﺜﺮ ﻣﻦ ﺳﺒﻌﺔ ﺃﻳﺎﻡ ﺳﻴﺮﻓﻊ ﺍﻟﻄﻠﺐ ﻟﻠﺪﺭﺍﺳﺔ ﻣﻦ ﺍﻟﻠﺠﻨﺔ ﺍﻹﺩﺍﺭﻳﺔ ﻭ ﺍﻟﻄﺒﻴﺔ ﻭ ﻓﻲ ﺣﺎﻝ ﺍﻟﻤﻮﺍﻓﻘﺔ ﻳﺘﻢ ﺍﻗﺘﻄﺎﻉ‬
‫ﺍﻷﺣﻮﺍﻝ ﺳﻴﺘﻢ ﺧﺼﻢ ﻗﻴﻤﺔ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﺘﻲ ﺍﺳﺘﻔﺎﺩ ﻣﻨﻬﺎ ﺍﻟﻤﺮﺍﺟﻊ – ﺗﻄﺒﻖ ﺍﻟﺸﺮﻭﻁ ﻭﺍﻷﺣﻜﺎﻡ‬.
Our guests would like to inform you that if no service is obtained, the guest is entitled to a refund within seven days of the payment date, after seven days the application will be submitted for study from the
Administrative and Medical Committee if approved, 10% of the amount paid will be deducted for financial and administrative expenses.
In any case, the coast of the services which guest benefited will be deducted - the terms and conditions apply.
Invoice validation 14 days for one shot service
‫ ﻳﻮﻡ ﻟﺨﺪﻣﺎﺕ ﺍﻟﻤﺮﺓ ﺍﻟﻮﺍﺣﺪﺓ‬14 ‫ﺍﻟﻔﺎﺗﻮﺭﺓ ﺻﺎﻟﺤﻪ ﻟﻤﺪﺓ‬
Invoice validation 6 Months for Packages
‫ ﺷﻬﻮﺭ ﻟﺨﺪﻣﺎﺕ ﺍﻟﺒﺎﻗﺎﺕ‬6 ‫ﺍﻟﻔﺎﺗﻮﺭﺓ ﺻﺎﻟﺤﺔ ﻟﻤﺪﺓ‬
VAT Registration No : 310152224710003 ‫ﺭﻗﻢ ﺗﺴﺠﻴﻞ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬ Treating Doctor : Dr HEBAH YOUNES ‫ﺍﻟﻄﺒﻴﺐ ﺍﻟﻤﻌﺎﻟﺞ‬
Address : ‫ ﺍﻷﺣﺴﺎء‬، ‫ ﺷﺎﺭﻉ ﺍﻟﻈﻬﺮﺍﻥ‬- ‫ﺣﻲ ﺍﻟﻴﺤﻴﻰ ﻓﻲ ﺍﻟﻤﺒﺮﺯ‬

{ENSGN#80,20#Patient#001}
Received by ‫ﺍﻟﻤﺴﺘﻠﻢ‬ Prepared by : ALYAA MATOQ ALYAHYA

‫ ﻣﻦ ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﺪﻓﻮﻉ ﻣﻘﺎﺑﻞ ﻣﺼﺎﺭﻳﻒ ﻣﺎﻟﻴﺔ ﻭﺍﺩﺍﺭﻳﺔ " ﻭﻓﻲ ﺟﻤﻴﻊ‬%10 ‫ﺿﻴﻮﻓﻨﺎ ﺍﻟﻜﺮﺍﻡ ﻧﻮﺩ ﺇﻋﻼﻣﻜﻢ ﺑﺄﻧﻪ ﻓﻲ ﺣﺎﻝ ﻋﺪﻡ ﺍﻟﺤﺼﻮﻝ ﻋﻠﻰ ﺃﻱ ﺧﺪﻣﺔ ﻳﺤﻖ ﻟﻠﻤﺮﺍﺟﻊ ﺍﺳﺘﺮﺩﺍﺩ ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﺪﻓﻮﻉ ﺧﻼﻝ ﺳﺒﻌﺔ ﺍﻳﺎﻡ ﻣﻦ ﺗﺎﺭﻳﺦ ﺍﻟﺪﻓﻊ ﺃﻣﺎ ﺑﻌﺪ ﻣﺮﻭﺭ ﺃﻛﺜﺮ ﻣﻦ ﺳﺒﻌﺔ ﺃﻳﺎﻡ ﺳﻴﺮﻓﻊ ﺍﻟﻄﻠﺐ ﻟﻠﺪﺭﺍﺳﺔ ﻣﻦ ﺍﻟﻠﺠﻨﺔ ﺍﻹﺩﺍﺭﻳﺔ ﻭ ﺍﻟﻄﺒﻴﺔ ﻭ ﻓﻲ ﺣﺎﻝ ﺍﻟﻤﻮﺍﻓﻘﺔ ﻳﺘﻢ ﺍﻗﺘﻄﺎﻉ‬
‫ﺍﻷﺣﻮﺍﻝ ﺳﻴﺘﻢ ﺧﺼﻢ ﻗﻴﻤﺔ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻟﺘﻲ ﺍﺳﺘﻔﺎﺩ ﻣﻨﻬﺎ ﺍﻟﻤﺮﺍﺟﻊ – ﺗﻄﺒﻖ ﺍﻟﺸﺮﻭﻁ ﻭﺍﻷﺣﻜﺎﻡ‬.
Our guests would like to inform you that if no service is obtained, the guest is entitled to a refund within seven days of the payment date, after seven days the application will be submitted for study from the
Administrative and Medical Committee if approved, 10% of the amount paid will be deducted for financial and administrative expenses.
In any case, the coast of the services which guest benefited will be deducted - the terms and conditions apply.
Invoice validation 14 days for one shot service
‫ ﻳﻮﻡ ﻟﺨﺪﻣﺎﺕ ﺍﻟﻤﺮﺓ ﺍﻟﻮﺍﺣﺪﺓ‬14 ‫ﺍﻟﻔﺎﺗﻮﺭﺓ ﺻﺎﻟﺤﻪ ﻟﻤﺪﺓ‬
Invoice validation 6 Months for Packages
‫ ﺷﻬﻮﺭ ﻟﺨﺪﻣﺎﺕ ﺍﻟﺒﺎﻗﺎﺕ‬6 ‫ﺍﻟﻔﺎﺗﻮﺭﺓ ﺻﺎﻟﺤﺔ ﻟﻤﺪﺓ‬