Dr. Petronilo V. Seares Sr.

Memorial Hospital
Zone 3, Bangued, Abra
Contact No/s: 752-5963/ 752-7601

STATEMENT OF ACCOUNT

SOA REFERENCE NO.:

2021-08-00167

Name of Patient: PEDRO VALERIO NAVARRO Age: 41

Address: Bangued, Abra Date & Time Discharge:_____
Final Diagnosis: N3B3 Via Normal Operation Date & Time Admitted:
Other Diagnosis: Right Foot Infection 06/21/2021/ 8:00 AM

SUMMARY OF FEES

Particulars Actual Charges

HOSPITAL CHARGES:
Room & Board 10,000.00
Drugs & Medicines 4,600.00
Medical Surgical Supplies 3,500.00
Laboratories 1,534.00
X-ray 450.00
ECG
Oxygen
Others 3,000.00
Operating Room Fee 3,000.00

Professional Fees:

Dr. Vilma S. Alzate 10,000.00

SUB TOTAL 10,000.00

GRAND TOTAL 36,084.00

Prepared by:

ELOISA N. ADAME
Billing Clerk
(Signature over printed name)
Date Signed: 06/22/2021

NOTE:

1. Fill out the form Legibly

2. The member/ patient/ authorized representative should not sign a blank SOA
3. Printed copy of SOA or its equivalent should be free charge