CHARGE SLIP

NAME OF PATIENT: _____________________________________________OP: DEPT:/SECTION: DATE

IP RM NO. DR

CODE PROCEDURE/ITEMS QTY UNIT COST TOTAL

NBST KIT -- 1,750.00
CORD CARE FEE -- 90.00
ALCOHOL USED
CLEAN GLOVES 3 PAIRS
GAUZE 4X8 (5PCS PER PACK) 1 PACK
CORD CLAMP 1
GLOVES 6.5 3
GLOVES 7.0 3
SUCTION CATHETER 8 1
UNDERPAD 2
SYRINGE 1CC 2

PREPARED BY: _____________PAYMENT RECEIVED BY: _________ DATE RECEIVED: __________ OR NO.: _______

CHARGE SLIP
NAME OF PATIENT: _____________________________________________OP: DEPT:/SECTION: DATE
IP RM NO. DR

CODE PROCEDURE/ITEMS QTY UNIT COST TOTAL

ERYTHROMYCIN EYE OINTMENT USED USED
VITAMIN K AMPULE USED USED
HEPA B VACCINE USED

TOTAL

PREPARED BY: _____________PAYMENT RECEIVED BY: _________ DATE RECEIVED: __________ OR NO.: _______