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TRANSACTION FORM
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CLINIC USE Date

Clinic Code
Clinic Name

Company Name

Patient Name

Patient Card No.

VISIT INFORMATION
Diagnosis Code 1 2 MC Days

Visit Date Visit Time am/pm

CHARGES RM Itemization
Consultation Name of Drug/Injection Quantity RM
Medication
Injection
Special Medication
Others (Please Specify)

Total amount charged

Item(s) need to be adjusted: MC Amount Others Please Specify

Remarks:

Doctor's Name :

Signature Clinic Rubber Stamp

RED ALERT USE Adjustment Done Not Done

Transaction Approval Code [1][2]

Old Transaction Number [3]

New Transaction Number [3]

Remarks :

Name / Signature Date