INVOICE a @: Registration No / OPA2012170032 / 00-10-89-05 Invoice No +01V2012170038 MR Name : SARTIKA ANISAH PUTRI Invoice Date : 17-Dec-2020 10:05 Address 3 JL.RAYA TENGAH I NO.43 Registration 17-Dec-2020 09:24 Date Patient Type PRIVATE Primary Doctor: dr. ka Sri Purnamaningsih, SpOG [Ro None eset [_ay[uom_ | —Aroun] piss] Paton! - = = — |CONSULTATION AND Visit | 1 OPO CONSULTATION SPECIAL 6 dr. Ika Sri Purnamaningsih, SpOG | (265,000) ) 2s.) | Jenoceoure ano rierapy | 2 |PROSEDUR USG TRANSVAGINAL dr. ka Sri Pumamaningsih, SpOG 1 -458,000| 0} 458, no} SPecat Doctor| | |pRucs | FOLAMIL GENO CAP @0 FARMAS! ssloap | aso7e| ol asa, | [UTROGESTANZ00NG CAP VAGAP Fann ssjear | arazis| | arate, OTHER SERVICE AND CHARGE | ! | | 5 [sarervcean ere) - SAPumamaningsh, $06 || 15,000, 15,000 | o>fomen transaction dr. ea St Pumaneningsih, 8907} 2.23] —_ 2128) “I i ___ endo sere : aS SUBTOTAL: 0690 01298902 ADMIN CHARGE so,000 ROUNDING : TorAL: 1,347,000 PAYMENT 1.247.000 BALANCE: 0 INWORDS PATIENT: Satu jit tiga tus empl puluh uh bu rupah PATIENT RECEIPT / KUITANSI me [type [Date [Payment Mode [Account No [esoun ame [Desaiion stier — Pate Poymer [171220 [Dept care foxx Burm NS Janos, nerne: coos |Se68 FH 7000 ~ a : 7 1,347,000 [ PF Sioa Traonat HoSpRat THR NPWE OTTER TSE OEE GO ioe beste sebagat Fakur Paek seal seroen Poston i Drektur Jena Pk No. 27PH20TT Tanggal To septete oot [ its |-Imoice nl merpakantanda ema peribayson rer sel otompel lh ask ASR, This en fel payment rece upon cache sary, - Brana yang sudan bel tdak copa dkaroher can, Change oretum ater purchase af ot ones Unt oat on, nego tem tl fan soda emaeuk PPN VAT s included for pharmacy tem) pices on sual ere | Unk rowat rap, tem otis argos cou at Lekahena Pharmacy tem (snot subject to VAT on patent ee Invoice ini merupakan bukti pembayaran yang sah Printed on 17-Dec-2020 10:06 by Glaadys Herlyn Lekahena