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  • Medical Invoice Template - Jotform PDF Editor

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    Cath Diverson
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    This medical invoice from July 10, 1960 contains information about supplies prescribed to patient Lettie Roddam by Dr. Kelsey Di Francecshi including the supply descriptions, quantities, unit prices, and total amounts. A total of $226 was due for 10 different medical supplies prescribed to the patient. The invoice provides contact and billing information for both the patient and prescribing physician.

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    This medical invoice from July 10, 1960 contains information about supplies prescribed to patient Lettie Roddam by Dr. Kelsey Di Francecshi including the supply descriptions, quantities, unit prices, and total amounts. A total of $226 was due for 10 different medical supplies prescribed to the patient. The invoice provides contact and billing information for both the patient and prescribing physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    9 views1 page

    Medical Invoice Template - Jotform PDF Editor

    Uploaded by

    Cath Diverson
    This medical invoice from July 10, 1960 contains information about supplies prescribed to patient Lettie Roddam by Dr. Kelsey Di Francecshi including the supply descriptions, quantities, unit prices, and total amounts. A total of $226 was due for 10 different medical supplies prescribed to the patient. The invoice provides contact and billing information for both the patient and prescribing physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    Medical Invoice

    Invoice Number AU326748

    Order Date July 10, 1960

    Patient Information Prescribing Physicians Information

    Lettie Roddam Kelsey Di Francecshi

    (555) 555-5555 (555) 555-5555

    8 Larry Park, 5 Birchwood P


    New Orle, Lo, 70116
    United States

    Medical Equipment/Supply
    Description Quantity Unit Price Amount

    1 Medical Supply 1 1 10 $10

    2 Medical Supply 2 2 20 $40

    3 Medical Supply 3 1 30 $30

    4 Medical Supply 4 3 10 $30


    5 Medical Supply 5 5 10 $50
    6 Medical Supply 6 1 20 $20
    7 Medical Supply 7 2 15 $30

    8 Medical Supply 8 3 3 $9

    9 Medical Supply 9 1 5 $5

    10 Medical Supply 10 2 1 $2

    Payment Method Cash Total Amount 4755

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