MEDICAL RECEIPT

From To Invoice No. #PN65221

DR. V JAY JAGANATH Ms. N R SPAMER
PR. No. 1471895 Mr. Z SPAMER Invoice Date: 06/05/2022
B. Sc. (U.D.W) M. B. Ch.B.) ( NTL. ) No. 5 Dove Place
No. 4 Randles Rd Hatton Estate, Pinetown Date: 06 MAY 20221
Sydenham 3610
4091

TEL: (031) 467 1865

RES: (031) 330 1890
FAX: (031) 256 5704
EMAIL: jayjaganath@hotmail.com

Handed
Medical Report Medication Qnt Total
IN/OUT
500mg Prescription
Recurrent abscesses x 6 episodes w high fever
Sulfamethoxazole ×2 100ml
+38°C
250mg advil ibprofen
50mg Steroid Ointment Prescription
Koebner Phenomena bacterial infections (4
15mg biologyical ×2 700ml
years)
injection
250mg tigrcycline Prescription
×1 50mg
L/ear infection + L/R Glan enlargement 100mg Aurone Forte
×1 15mg
drops

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 Subtotal R400.00

Tax

Payment method CASH

Total R400. 00

Credit Card
Is
☐ Visa ☐ MasterCard ☐ Discover ☐ American Express

Cardholder Name ___________________________

Account/CC Number ___________________________
Expiration Date ____ /____
CVV ____
Zip Code _______

I authorize the above named business/individual to charge the credit card indicated in
this authorization form according to the terms outlined above. This payment
authorization is for the goods/services described above, for the amount indicated above
only, and is valid for one (1) time use only. I certify that I am an authorized user of this
credit card and that I will not dispute the payment with my credit card company; so long
as the transaction corresponds to the terms indicated in this form.

SIGNATURE ___________________________ DATE _____________________

(cardholder name)

Bank EFT

Name on Bank Account: _________________________

Street Address: _________________________
Bank Name: _________________________
Account Number: _________________________
Routing Number: _________________________
Account Type: _________________________

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