The Health Centrum, Inc.

Brgy. Banica, Roxas City, 5800, Capiz

Others Charge Slip
Name:
DE LOS SANTOS, MARGIE
DIESTRO
Hospital Number: 00015640 Date: 04/18/2024 13:12

QTY Charge Unit Price Total Price

1.00 0.00 0.00

1.00 0.00 0.00
OTHER HOSPITAL CHARGES
1.00 Medical Abstract 300.00 300.00
2.00 Certified True Copy 8.00 16.00
Medical Records (per
page)
1.00 Doctor's fee-Medical 100.00 100.00
Certificate fee
1.00 Doctor's fee-Medical 100.00 100.00
Abstract
1.00 Medical Certificate Fee 170.00 170.00

Page: 1 / 2
 The Health Centrum, Inc.
Brgy. Banica, Roxas City, 5800, Capiz
Others Charge Slip
Name:
DE LOS SANTOS, MARGIE
DIESTRO
Hospital Number: 00015640 Date: 04/18/2024 13:12

QTY Charge Unit Price Total Price

TOTAL: 686.00
Entered by: VILLARUZ, VINCENT

Page: 2 / 2