GILI MEDICAL SERVICE

GENERAL PRACTICIONER
DUSUN GILI AIR, GILI INDAH, PEMENANG, LOMBOK UTARA
Telp/WA : 087864353202 / 08170 991 991

INVOICE
Invoice Number : 01/TMS/240328
Full Name : ELIZA KALOCSA
Date of birth : 29.07.2014
Nationality : Hungarian
Address In Lombok : Gili Air
Date of admission : 28/03/2024
Date of discharge : 28/03/2024
IN SETTLEMENT OF FOLLOWING
NO DESCRIPTION QTY AMOUNT (IDR)
CONSULTATION AND VISIT
Physical examination and consultation 1 600.000,00
PROCEDURE AND THERAPY
Applying infusion 1 100.000,00
Removing infusion 1 100.000,00
Ringer lactat 1 400.000,00

DRUGS
Ranitidine Injection 1 220.000,00
Norages Injection 1 220.000,00
Ondansentron Injection 1 220.000,00
Scopma Plus 10 220.000,00
Zentivar 10 220.000,00
Lokev 10 220.000,00
CONSUMABLES AND MEDICAL SUPPLIES
Infus set makro 1 300.000,00
Abocath 24 2 400.000,00
Plester 1 35.000,00
Spuit 3 cc 1 40.000,00
Alcohol Swab 3 10.000,00
OTHER SERVICE AND CHARGE
Observation 1 400.000,00
Call out service 1 400.000,00
TOTAL AMOUNT 4.095.000,00

THIS INVOICE IS A LEGITIVE PROOF OF PAYMENT Gili Air, 2024-03-28

Dwi Putra Asmianto

Medical Service Officer