Patient Bill: Collection Date & Time: Test Name Reporting Date & Time Rate SR

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Patient Detail: Registration Location: Reference: Patient Number:

Noor Ul Basar . KPK Swabi: DHQ Hospital Blue Card - Diabetes Care Program
63901-23-12829158
Age/Sex : Registration Date: Consultant: Case Number:
32 (Y) / M 03-May-2024 12:37 CARD MEMBER 63917-03-05
Note : ,,,

Patient Bill Collection Date & Time: 03-May-2024 12:37

Sr. Test Name Reporting Date & Time Rate


1 Glycosylated Hemoglobin (HbA1c) May 04, 2024 - 04:37 2100.00

Total : 2100.00
Discount : 840.00
To Be Paid : 1260.00

Paid : Rs: 1260.00

Remarks : 1 Case Registration using Loyalty Card 2557000114969404


Registered By : FaheemSajjad4509

Collection Center How did we do? Please share Scan here to book home
your feedback sampling
Center Name : KPK Swabi: DHQ Hospital
Phone Number : 0345-8406805:0938-222295,
Contact Person : Mr.Ibrahim Zeb
Email :
Address : Illaj Medical Centre, Near National Bank, Jahangira
Road, Swabi-KPK

I HAVE READ AND UNDERSTAND THIS CORRESPONDING TEXT AND HAVE ASSUMED ALL RISK(S) INVOLVED IN PARTICIPATING IN THIS TESTING. I RELEASE AND HOLD HARMLESS
CHUGHTAI LAB AND ANY AUTHORIZING PHYSICIAN, INCLUDING THEIR EMPLOYEES, AGENTS AND CONTRACTORS, FROM ANY LIABILITY, CLAIM, INJURY, DAMAGES, ATTORNEYS’
FEES OR HARM OF ANY NATURE THAT MIGHT RESULT FROM THE TESTING, MONETARY OR OTHERWISE, INCLUDING THOSE INVOLVING MY PHYSICAL OR MENTAL HEALTH,
MEDICAL TESTING PROCEDURES, ERRORS IN TEST RESULTS. IN ADDITION, I HEREBY CERTIFY THAT ALL INFORMATION LISTED ON THIS FORM IS TRUE. I UNDERSTAND THAT ANY
OBJECTIONS/EXPLANATIONS IN THIS REGARD CAN ONLY BE MADE/ASSERTED THROUGH ELECTRONIC MAIL ADDRESSED TO CHUGHTAI LAB AT “info@chughtailab.com” WITH
SUBJECT LINE TITLED AS “OBJECTION TO WAIVER OF TEST”, AND THAT ABSENT SUCH AUTHORED DIGITAL MAIL WITHIN THREE DAYS OF RECEIPT OF SAME, ALL OBJECTIONS
ARE/SHALL FOREVER WAIVED.
03111456789 info@chughtailab.com Al-Azam Plaza Stat-Lab Dabgari-Peshawar www.chughtailab.com

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