Bill of Supply cum Receipt Original Copy

Fortis Memorial Research Institute Pvt Ltd

Sector - 44, Opposite HUDA City Centre, Gurugram, Haryana 122002

Patient Information:

Name: Ritik Yadav

Address: Hz 444 Near Mamta Bakery Block D Raj Nagar Extension, II, Delhi New Delhi,
110045

Phone Number: 9053370682

Patient ID: 1897356

Hospital Information:

Hospital Name: Fortis Memorial Research Institute

Address: Sector - 44, Opposite HUDA City Centre, Gurugram, Haryana 122002

Phone Number: 088600 22554

Date Information:

Date of Admission: 26-10-2023

Date of Discharge: 27-10-2023

Date of Bill: 28-10-2023

Details of Charges:

Description Unit Cost Quantity Total Cost

Room Charges ₹50,000 2 days ₹100,000

Doctor's ₹66,000 3 visit ₹66,000

Consultation Fees

Nursing Charges ₹37,000 1 service ₹37,000

Laboratory Test ₹28,500 1 service ₹28,500

Fees

Medication Fees ₹5,400 1 service ₹5,400

Other ₹101,778 3 service ₹101,778

Services/Charges
(e.g., X-ray, MRI)

Subtotal ₹338,678

Any Discounts -₹33,000

Total Amount ₹305,678

Amount Paid ₹305,678

Balance Due ₹0

Payment Information:

Total Amount: ₹305,678

Amount Paid: ₹305,678

Balance Due: ₹0

Fortis Memorial Research Institute Pvt Ltd

Terms & Conditions

1. Interest 18% p.a. will be charged if the payment is not made within the
stipulated time.

2. All disputes will be subject to Delhi Jurisdiction only.

CIN: U74140DL2015PTC279229
Authorised Signatory

PAN: AAACZ8318D