(COPY) OUTPATIENT INVOICE Page : Page 1 of 2

Printed by : ANISA Print Date : 03/09/2021 6:08 pm

Bill No : OCS210115969 Patient Name : Mrs. NYI DEWI KURAESIN

Bill Date : 03 /09/2021 5:43
OP No : OPV2109030828 MRNo : MHJS.0000324014
Age : 33 Year(s) 6 Month(s) 28 Day(s)
Gender : Female

No Service(s) Qty UOM Price Amount

Administrative Charges
1 Administration Fee 1 100,000 100,000

Bedside Procedures
2 Cauter Machine ( Sewa Per 1 Alat ) 1 880,000 880,000
3 INSTRUMENT OFFICE HYSTEROSCOPY 1 1,250,000 1,250,000

Consultation
4 dr. TRICIA DEWI ANGGRAENI,SpOG(K) Onk - 1 400,000 400,000
OBSTETRICS AND GYNECOLOGIST
Consumables
5 CONECTING TUBE 2 FUNEL HOSPITEC 1 EACH 93,632 93,632
6 VAGINAL SPECULUM M 1 EACH 16,940 16,940
7 APRON WHITE AP88 2 PCS 4,312 8,624
8 TRANSOFIX B'BRAUN 1 EACH 15,400 15,400
9 PAKET STERIL KASSA SURGILAB 6 X 6 CM (ISI 2 EACH 22,753 45,506
5)
10 PAKET STERIL KAPAS APPLICATORS 15,2 CM 1 EACH 15,936 15,936
(ISI 3)
11 UNDERPAD STERIL 60 X 90 2 PCS 11,743 23,486
12 STERIL GLOVE GAMMEX LATEX PF NO. 7 2 EACH 38,500 77,000
13 STERIL GLOVE GAMMEX LATEX PF NO. 6 2 EACH 38,500 77,000

Investigation
14 PA SMALL HISTOLOGY (JARINGAN KECIL < 1 1,350,000 1,350,000
3CM)
OP/IP Procedure
15 EXTRACTION IUD 1 590,000 590,000
16 COLPOSCOPY 1 1,515,000 1,515,000

Pharmacy
17 INTERDOXIN 100 MG CAP 15 CAPSUL 10,164 152,460
(COPY) OUTPATIENT INVOICE Page : Page 2 of 2
Printed by : ANISA Print Date : 03/09/2021 6:08 pm

Bill No : OCS210115969 Patient Name : Mrs. NYI DEWI KURAESIN

Bill Date : 03 /09/2021 5:43
OP No : OPV2109030828 MRNo : MHJS.0000324014
Age : 33 Year(s) 6 Month(s) 28 Day(s)
Gender : Female

No Service(s) Qty UOM Price Amount

18 NACL 0,9% INFUS 1000 ML OTSUKA 1 EACH 42,966 42,966
19 PODOPHYLLIN TINCTURA 25% 3 ml 6,646 19,938
20 PROFENID 100 MG SUPP 1 SUPPO 24,114 24,114

Grand Total : 6,698,002

Rounded Bill Amount : 6,698,000

Amount in Words : six million six hundred ninety eight thousand Rupiahs
Received payment from : Mrs. NYI DEWI KURAESIN
DebitCard ******************596 VISA CARD . 6,698,000

Ending Balance : 0

SEMOGA SEHAT SELALU KOTA ADM. JAKARTA SELATAN ,

1 . This bill is due and payable on presentation. 03-Sep-2021
2 . Charges not accounted for at the time of discharge will be billed later. Mayapada Hospital
3. Purchased items cannot be refunded. CASHIER : ANISA