MEDICAL INVOICE

Bill From Bill To Invoice No. 34566755

Name: DR. Theresa MOORMAN Name: Elsa Tillman
Company Name: Beverly Hospital Street Address: Old England Rd, Invoice Date: 2010-02-26
Hospital Newton, MA 0246
Street Address: 85 Herrick St, USA Due Date: 2010-02-28
Beverly, MA 01915, United States Phone: 8337363236
Phone: +1 617-243-6000

Medical Services Performed Rate Total

Head Computed Tomography Scan $400 $4000
Rectal Examination $100 $1000
Neurologic Examination $1659 $1659
Blood test $1200 $1200
Chest X-ray $2800 $5600
Intensive Medical care $15000 $300000
CAT Scan (2) $3000 $6000
Pelvis Imaging $2000 $2000
Medication-on-admission (Prozac, tetracycline) $1137 $1137
Medication (Tylenol, Motrin) $48 $48
Serum and Urine Examination $100 $100
Subtotal $57764
Sales Tax $1600
Other
Total $54344

Terms and Conditions

Thank you for your business. Please send payment within 2 days of receiving this invoice. There will be a
2% per day on late invoices.

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Cardholder Name: Mrs. TRAUMA

Account/CC Number: 0473626227272
Expiration Date : 05 /29
CVV 087
Zip Code : 46379

I authorize the above named business/individual to charge the credit card indicated in
this authorization form according to the terms outlined above. This payment
authorization is for the goods/services described above, for the amount indicated above
only, and is valid for one (1) time use only. I certify that I am an authorized user of this
credit card and that I will not dispute the payment with my credit card company; so long
as the transaction corresponds to the terms indicated in this form.

SIGNATURE : Mrs. TRAUMA _________________________ DATE :

(cardholder name)

Bank Wire

Name on Bank Account: _________________________

Street Address: _________________________
Bank Name: _________________________
Account Number: _________________________
Routing Number: _________________________
Account Type: _________________________

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Email: __________________________

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