+1 234 567 8899
contact@invoice.com

4510 E Dolphine St, IN 3526 Hills Road, New York, USA

# INVOICE

Patient Info:

## Jordon Smith

Phone: +1 562 563 8899
Bad No: G5

Invoice No:
#DI56789
Invoice Date:
15/12/2024

Patient ID | Age | Admit Date | Insurance
--- | --- | --- | ---
45123 | 35 Years | 30/11/2022 | Yes

S No. | Description | Price | Amount
--- | --- | --- | ---
1 | All Blood Test | $200.00 | $200.00
2 | Sugar Test | $40.00 | $40.00
3 | Surgeon Fee | $60.00 | $60.00
4 | Medical Medicine Bill | $125.00 | $125.00
5 | Hospital Usage Bill | $80.00 | $80.00

### Hospital Rules:

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Sub Total: | $505.00
Tax (18%) | $90.90
Grand Total: | $595.90

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### This is computer generated receipt and does not require physical signature.