Fortis Healthcare Limited

Address: B-22, Sector 62, Gautam Buddh Nagar, Noida, Uttar Pradesh 201301

Phone: +91-11-4055-4055 | Email: contactus.noida@fortishealthcare.com

Patient Information

- Patient Name: [Name]

- Patient ID: [ID]

- Age: [Age]

- Gender: [Gender]

- Address: [Patient's Address]

- Contact Number: [Patient's Contact Number]

Admission Details

- Admission Date: [Date]

- Discharge Date: [Date]

- Room Type: [Type]

- Consulting Doctor: [Doctor's Name]

Bill Details

Description Quantity Rate Amount

Room Charges [Qty] [Rate] [Amount]

Doctor Consultation Fees [Qty] [Rate] [Amount]

Nursing Charges [Qty] [Rate] [Amount]

Lab Tests [Qty] [Rate] [Amount]

Medications [Qty] [Rate] [Amount]

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 Fortis Healthcare Limited

Address: B-22, Sector 62, Gautam Buddh Nagar, Noida, Uttar Pradesh 201301

Phone: +91-11-4055-4055 | Email: contactus.noida@fortishealthcare.com

Surgery Charges (if any) [Qty] [Rate] [Amount]

Miscellaneous [Qty] [Rate] [Amount]

Total Amount [Total]

Discounts (if any) -[Discount]

Net Amount Payable [Net Amount]

Payment Details

- Mode of Payment: [Cash/Credit Card/Debit Card/Insurance]

- Transaction ID: [ID]

- Payment Date: [Date]

Authorized Signatory

Name: [Name]

Designation: [Designation]

Signature: ______________________

Note

This is a computer-generated document and does not require a signature.

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