Download Free Medical Invoice Template by HC12091218250

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									Free Medical Invoice Template

___________________Medical Invoice
[State the name of the healthcare organization]
__ [Provide a mission statement of the particular organization at the header part]

Invoice Date: ________________[dd/mm/yy]

Invoice Number: ___________________

Contact Information : [State the required contact details of the health care
organization]

Address: _____________________
_________________________

Phone no.:____________
Patient Information:

Name of the Patient: ____________________________

Address:_______________________

Age:
Gender: [Male / Female]

Department: [State the hospital department in which the patient is admitted or
undergoing check-up.]
Bed/Ward Number:
Doctor in Charge: ______

Admission Date:_______ [dd/mm/yy]

Date of Discharge:_______

Payment Details: [Specify the mode through which the patient is paying off the
bill.]

Mode:

Bank Account no.:

Invoice Details: [Specify the details of the services rendered along with the
expenses incurred by the patient.]

Services                          Charge Amount




Discount:

Service Tax:
Total Amount:

Signature: [Provide the signature of the hospital-in-charge]

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