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    Akbar Shah

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    48 views13 pages

    Akbar Shah

    Uploaded by

    MohdShahrukh
    Akbar Shah

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 13
    Nexteare” Tour Hea Managed wit Care REIMBURSEMENT FORM 24 hour Tel 042708800, Fox: 04 2708692 Please Complete Clearly (All Fields Mandatory) FORM No: ADMINISTRATIVE Hesltheare Provider: Patient's Name: MDG SHG Date of Service’ ad mm Manny Patients Te: DOB ddimmiyyy [Sex OF OM mal adcress Emirates 1D No: mal sat insurance Company Account Name UAE TEAN Number UAE Bank Name: UAE Swift Code ‘SUBJECTIVE (To be completed by Physician) ‘Symplom(s} As Described by Patient (CHIEF COMPLAINT) Date of Present Symptom Onset: a What date did the Patient first feel seme / similar symptom): ‘a im Ts the Patient under any iype of treatment/ Mads: LIVES C) NO If yes, indicate what assessment and since when: ‘OBJECTIVE / ASSESSMENT (To be completed by Physician) Vital Signs T: Pasi Medical & Surgical History: ial Detals § Descrpion of Present Cama Cause: (Physical liness CiAccident CMatermty Clpreventve CiPsychlatic [iDental CWerk Related Caeute Chronic Confined CSuepected ClOther “Rasessment/ Dagnosist_nocnTe ncnosisnoTSWTOW Diagnosis Code L @ture Uppis oto Oicsammy la@iuienl toe | 2 Ts Assessment / Diagnosis related to another Assessment? (YES ONO yes, specify: le. Retnopathy related to Diabetes MEDICAL PLAN terized Orghalimvcces and Applicable Presciption / Reports /Rasuts must be enclosed o constr cam TD Consuttation Cost O Physiotherapy Goat Pharmacy Cost | Ei Laboratory / Radiology / Other Cost TOTAL CHARGES as a RT GT aaa a com 7 iacharge Suman hanied vac, Reports & Rect ached? ag Pe Tereby BUIROED any Peace Pro Wee: EMGVar iseiag Rae IN ‘rather Organization fo rlease any information regarding My Noho & 5 ‘tee! conan & hry 10 NECARE fore purpose oF ‘otrmhing uronce bens. Enpit__ " Gere Pacttonsr Siohaiurs SSSAWB knoe po ci uRaLaua Patent Signature (Parent fino ave 12th street, Behind Bin Sougat ‘AL RASHIDIYA. Centre. Oubal UAE AL NOC +971 4 2862410 erase PaligiNems: AKBAR SHAR ARIF GUL Date PRN 307716 GonderiAge: TPAlns: “Cash Policy Numb Network: = Mobi: Emirates ID: 784-1906-03160726 Diagnosis Pimay TOS “Reais upper resptary wedi, Secondary 100 ‘Acute nasopharyngits commen col Secondary 29.00 ‘Acute gastts without bleeding Secondary R508 Fever, unspecified ‘Secondary R05 Cough ‘Secondary : M794 Nyalgia Secondary R082 Wheezing Prescription PANTONIX- PANTOPRAZOLE (AS SODIUM) [20 MG]-ENTERIC COATED 5 Days ‘TABLETS (908, BLISTER) -0005-242601.0361 JULMENTIN FORTE - CLAVULANIC ACIDIAMOXIGILLIN [125 MGI500MG]- 5 Days TABLETS (208, BLISTER PACK) -0005-116207-1171 MAXIGESIC -IBUPROFEN/PARACETAMOL [150 MGI500 MG] - FILM 3 Days COATED TABLETS (G25, BLISTER) 2027-560101-0991 (ONCET - CETIRIZINE HCL [10 MG] - FILM COATED TABLETS (840, Says BLISTER PACK) 0097-123701-0381 BROMOL 30MG/SML - AMBROXOL HCL [30 MG/SML]- SYRUP (SUGAR S Days FREE) ({00ML, GLASS BOTTLE) -140%-#42001-248t ‘Comments } Doctor Name License |= Dr Prajeesh Balachandran a, | DHAB-eaas16s i 2p thamedicine and report to nearest chys For pharmacy: Dispense the exact cuantiy. $ Aap \ TAX INVOICE /4i 42 3.538 Pharmacy Name, ABEERLAL NOOR PHARM: ce bE a ae Hager pharmacy Address’ RASHIDIYA Tolt/-sis: 04 2362305 Faxdil_-Sk 04 2591972 Pharmacy TRN Invals , OHA-F-0002584-110/01/0004013 Date/a: 82 24112/2019 21:27 Patient 0): WALKIN CUSTOMER Patient Contact Loyatty Cara: Served By/-k ,): Nishad Customer: WALKIN CUSTOMER item Dascription / sa! a, Expiryltet! @8~ Cadel Price Gross Disc Net Vai% Net inc VAT Dl lll ak lhe enh Saray the anys 1.JULMENTIN FORTE 625MG TAB 05 02/2022 - 0005-1 16207-1171 56.50 28.26 0.00 2825 000 28.25 2.XPEL 30MG®ML SYRUP 100ML 1 42/2021 - 0067-442001-2481 4250 1260 0.00 1250 000 1250 3 ARTIZ IMG TABLET 105 1 07/2021 - 0195-123701-0391 900 900 000 9.00 000 4. MAXIGESIC TAB 16S os 12/2021 - 2027-560101-0392 18.00 760 000 7.50 0.00 5.PAN 20MG TAB 30S (03/2020 - 0067-242801-1172 68.50 2260 000 2260 000 2260 Total Gross Ante 20! = AED 79.86, Total Discount Anas? AED 0.00 Total Net Anta! AED 79.86 Total VAT Amit. AED 0.00 Tatal Net include VATIa yiwAED 79.86 Ineurance Amie AED 0.00 Pay Antsy lato AED 79.86 Remain Amt Aes! AED 000 Paymant Mathad/sa! 4» — Credit Cara Accumulated Paints!!! 0.00 Managed by . Health First investment LLC. TRN no, 100268924600003 Exchange & Refund Policy eA Fat ae Medicine once sold cannot be Exchanged or Refunded as per MOH regulation. yet sha hy Yael Aah ia cls cold Ss 12th street, Behind Bin Sougat Centre - Dubai - UAE +971 4 2862410 AL RASHIDIYA ALNOOR POLY CLINIC! PalaniName: AKBAR SHAH ARIF GUL PAMRN 307716 TPAlns: Cash Nework: = Emirates ID: 784-1996.0916072.6 Date: ‘GenderiAge: Policy Number: Mobile: PARZAOIS MALE/ 33y 11M 230 osessoez7e Diagnosis Tas Take upper respiratory wecton, onepectied 00 ‘cute nasopharygt common cold), 28.0 Acute gests witout bleeding R508 Fever, unspecified 08 ough wre Myabla R062 Wheezing Prescription : eRK PANTONIX- PANTOPRAZOLE (AS SODIUM) [20 MG]-ENTERICCOATED 50ays, 10 ORAL Before Food-Take 1, 2mes TABLETS (GUS, BLISTER) 0005-242801-0381 ‘Day for § Daye JULMENTIN FORTE -CLAVULANIC ACIDIAMOXICILLIN [125 MGISODMG}-«SDays_ 10 ORAL Take 1,2tmes ADay for TABLETS (20, BLISTER PACK) 0005-116207-1171 Daye MAXIGESIC -IBUPROFEN/PARACETAMOL [150 MGj50O MG] - FILM 3Days 9 ORAL AferFood-Teke 1,3 times A COATED TABLETS (228, BLISTER) 2027-560103-0001 Day for 8 Daye OMCET - CETIRIZINE HCL [10 MG] -FILM COATED TABLETS (8408, 5Days 5 ORAL Before going to Bed at Nigh- BLISTER PACK) -0097-123701.0391 Take 1,1 time ADay for . Days ‘BROMOL SOMGISML - AMBROXOL HCI (30 MGISML]-SYRUP (SUGAR SDaye 1 ORAL Tako ML, 3 mas ADay for FREE) (1OOML, GLASS BOTTLE) -1401-442001-248t Sere Comments i Doctor Name ’ Dr Prajeesh Ce For pharmacy: Dispense the exact quantity. — 8 AL RASHIDIYAH i owe eiSovcnremmmsuon jill Apt) NI eam po. Box 97267 cil ae we § Behind Bin Sougat Centre we ies te + eet Rashidiya, Dubai wn Ss a) Tel: 04 286 2410 SOD ~E-mail: alnoor3@eim.ae ; ADIOS WBAL LAE Db: auarsiee hips 46204 PURCHASE IN’ TAIL NOSTPE SVE rare Bill Date: 24-12-2019 Paseo: @ USHAH ARIF GUL P-MRN + 307716 noun AeD 8s. of sesh Balachandran Printed Date 24-12-2019 eee unit tour Cashier Counter - 1 approval CODE 291705 § 1579100008 Sponsor Company ‘ Name: 8 ” 3 LMICORT BUDESONIDE [0.5 MG/ML] ri eo “AL INHALATION BULIZATION 1 30.00 GENO Raralan PARACETAMOL [10 MG/ML] IV 1 50.00 Discount: Total Amount:85.00 Bill Amount : EIGHTY FIVE ONLY 4 Card (Debit / Credit) Total Amount: 85.00 Received : EIGHTY FIVE ONLY ‘Note: This bill does not require a signature. Additional procedures, if any, will be charged extra. Theerenr ea] fe | ene | reso Sa - ger | ou are never perfect without a perfect smile Fixed braces for AED ea For Enquir Book your appointment with » Dr. Sibi MDS Specialist Orthodontics FIGHT TO GOOD HEALTH ALRASHIDIYA cial! gill Asti cape AL NOOR POLY CLUNEC | P.O. Box: 97267 Behind Bin Sougat Centre | Rashidiya, Dubat | Tel: 04 286 2410 Tt ‘E-mail: alnoor3@eim.ae IN TAIL Bill No: 829959 Bill Date: 24-12-2019 Name AKBAR SHAH ARIF GUL —-P-MRN 307716 Doctor: Dr Prajeesh Balachandran Printed Date 24-12-2019 Payment Mode: Cash Cashier Counter - 1 License No: 100224579100003 Cima] Name: Referral Patient ID: PULMICORT BUDESONIDE [0.5 MG/ML] ORAL INHALATION NEBULIZATION 1 1001 PERFALGAN PARACETAMOL [10 MG/ML] IV 0188-135906-2441 i Total Amount:85.00 Bill Amount : EIGHTY FIVE ONLY PAYMENT RECEIPT 1 Card (Debit / Credit) 85.00 Total Amount: 85.00 Received : EIGHTY FIVE ONLY does not require a signature. Additional procedures, if any, will be charged extra. For Enquiries, Please Call :04 286 2410 Book your appointment with » Dr. Sibi MDS Specialist Orthodontics THE LIGHT TO GOOD HEALTH _ www.alnoorrashidiya.com ALRASHIDIYA cat! gill Asti tl cape > PO. Box: 97267 Behind Bin Sougat Centre L NOOR ae Tel: 04 286 2410 tau | E-mail: alnoor3@eim.ae INVOICE DETAIL Bill No: 829915 Bill Date: 24-12-2019 Name AKBAR SHAH ARIF GUL. P-MRN : 307716 Doctor: Dr Prajeesh Balachandran _—Printed Date 24-12-2019 Payment Mode: Cash Cashier Counter - 1 . . Sponsor Company License No: 100224579100003 Name- ‘Referral Patient ID: 4 ‘APC-1060 Registration Fee 1 : "10.50 CONSULTATION GP - 1 _ 80.00 | me z A Totwle90.60, I Discount:0.00 Total Amount:90.50 4 Cash 90.50 Total Amount: 80.50 Received : NINETY FIVE FILLS ONLY Note:This bill does not require a signature. Additional procedures, if any, will be charged extra. efi | aera | Pa eel}? a =a You are never perfect without a pee smile Rirre ron nae eats AED Read Book your appointment with >» Dr. Sibi MDS Specialist Orthodontics sid TAX INVOICE/is + 3. Pharmacy Name. ABEER AL NOOR PHARM tet el te Aa pharmacy Address: RASHIDIYA Tota: 04 2362305 Faxl-st 04 2501372 Pharmacy TRN: Invi 38 DHA-F-GOO2584-1 1001 00041216 Datei, $0: 31/42/2010 24:40 Pationt/ al: WALKIN CUSTOMER Patient Contact: Loyalty Cara: ‘Served Byki: ADEL ALL : ‘Customer: WALKIN CUSTOMER Item Description / yaa i; yes Expiry! gy 45 Godel Price Gioss Disc Net Vat% Net inc VAT el aa mak thee att Aa alae 1. GORDEX 40MG CAPS 14'S 1 01/2021 - 0008-605201-1451 55.00 66.00 0.00 65.00 0.00 S500 2.DOMPY 10MG TABLET 30S. 035 02/2021 - 0031-168201-0391 14.00 462 0.00 462 000 462 Total Grass Antic s22 ABD 69.62 Total Discount Ames! AED 0.00 Total Net Ant fa! AED 69.62 Total VAT Anika AED 0.00 Total Net inckads VATIL= AAED 59 62 Insurance Amie ‘AED 000 Py Ariss 0 abs AED 5962 Remain An. AED 0.00 Payment Methods! <4. Credit Card Accumuiated Points/k23 si 0.00 Managed by : Health First Investment LLC. TRN no, 100268924600003 Exchange & Refund Policy eS eet Medicine once sold cannot be Exchanged or Refunded as per MOH regulation ela af Wasa Say Yael Sadia A THANK YOU FOR SHOPPING ‘www planetme ae WHATSAPP: +971 66 40 12000 Network» ‘Aber Al Noor Eiemiacyy 7 PURCHASE reat a re =a Seite scpimn Amount AED 59.70 a fae fees ae er Eons CUSTOMER COPY >> -fL-RASHIDIYAH - ‘uaa sci oo Saf et tor mee : aro oP w= nzz8 tare = a12as ine | sett a es 298 pos 1p: wuzisis7 MID: 462074008 PURCHASE VISA CVD Exe wwe ane one Sines SOOT PAN SED ND: 08 enount PED su.00 re ted 044510002 © HOM ye ie Yo Vist ca IRS HU < CUSTOMER COPY > 5 a ‘ i 12 + iM 0410012 + THE LIGHT TO GOOD HEALTH www.alnoorrashidiya.com = ALRASHIDIYA gill y gill 4zu4\ th uw Behind BirSougat Centre Rashidiya; Dubai 4 286 2410 831986 Bill Date: 31-12-2019 Name AKBAR SHAH ARIF GUL P-MRN : 307716 Doctor: Dr Prajeesh Balachandran Printed Date 31-12-2019 Payment Mode: Cash Cashier Counter - 1 ke " Sponsor Company License No: 100224579100003 Nese _ Referral Patient ID: 0006-238801-1021 ZOFRAN ONDANSETRON [2 MG/ML] IM, IV Discount:0.00 [ Total Amount:30.00_ Bill Amount : THIRTY ONLY | PAYMENT RECEIPT S.No. ReceiptReference Payment Type TT Received Amount! , Card (Debit / Credit) 30.00 | Total Amount: 30.00 [Received : THIRTY ONLY (Note: This bil does not require @ signature. Adltional procedures. if any, willbe charved ext 9 Ey earerenre| earl] fro | ur | ees | Sa A e never perfect without a perfect smile Recreate teety.t epee leo we aay Rae le precerrias Dr. Sibi MDS ‘Specialist Orthodontics 12th’ street, Behind Bin Sougat AL RAS EEA, Centre = Dubai - UAE AL NOOR +971 4 2862410 BOEeRINIS PalioniName: AKBAR SHAH ARIF GUL Date STBO1S PAMRN so7716 GenceriAge: MALE/33Y 11M 30D TPNins: Cash . Policy Number: = Nebiork: Mobile: ‘0568300274 Emirates ID: 78¢-1986.0316072.6 Diagnosis Famary ROS, Trspesifed abdominal pain Seconda Rit10 Vornting unspecd Prescription eR [Ricans ana eae nena = “Duration Gly” Route Instruction Be eDeN fo. ESOMEPRAZOLE (AS SODIUM) [40 NG] -CAPSULES SDays § ORAL Before Food-Take 1.1 time A (HARD GELATIN) (148, BLISTER) -0006-605301-1451 Day for 5 Days . MODODOM - DONPERIDONE [10 MG)-FILM COATED TABLETS (20'S, 3Days_« 6 ~—CORAL_ Take 1,2times A Day for3 Days BLISTER PACK) -0006-168201-0301 Doctor Name License Dr Prajeesh Balachandran ORAP-16448155 ¥e:ipatent develop alr cary cga lease stop he medic and report tea nc For pharmacy: Dispense the exact quantity. of United Arab Emirates Baked Ay pl LYN Resident Identity Card pie aye Hy a IO Number sg g Bijele Sian! a ‘Name Akbar Snah Arif Gul °, Nationality: Pakistan } Se aa a8. co nen ‘o7nsiz024 Sos TLAREO9740349997841 98603160726 8601012M2111 072PAK<<<<<<

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