Invoice No: #SM75692

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Date Of Services:
25 Feb 2022

IVONNE HOSPITAL

237 Roanoke Road, North York,
Ontario, Canada
demo@email.com
+1-613-555-0141

Patient Information

  • Patient Name:
    Micle Richard

    Patient Birth Date:
    32 Years Old - 22 July 1991

    Insurence Billed:
    WPS

  • Patient Name:
    123456789

    Services:
    Dental Treatment

    Due Date:
    25 Feb 2022

  • Address:
    4 Balmy Beach Road, Owen Sound, Ontario, Canada

Details Price Amount
Dental Treatment $60 $60
Bed Charge $120 $120
Consultant Surgeon Fee $25 $25
Medical Hospital Supply $30 $30
Nursing Service Charge $20 $20
Pay By
Credit Card - 236*****************
Amount: $ 113 - Due: $ 0

Tax:

Total Amount:

$13

$273

Note:

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