• 24 Hours Medical Emergency

• On Call/Home Visit Service

• Vaccination & IV Hangover Cure
• Pharmacy & Laboratory
• Medical Evacuation Service
• Cashless Medical Service
• Guarantee Medical Bill

CV. BRAHMEDIKA UTAMA INDONESIA

INVOICE

File number: MMC.202304.1824

Reff. Number : 32P231000492
Patient’s Name : Ramon Wassenberg
Nationality : Netherland
DOB : 23 February 1993
Current Address : Manayoga - Kuta Central Lombok
Type of Service : Home Care/Observation

No. Date of Description Unit Price Total Price (IDR)

Service (PCS)
1 02/04/2023 Registration 50.000 50.000
Doctor fee
2 - Examination and consultation 550.000 550.000
- House Call Visit 500.000 500.000
3 Medical Procedure
- Infusion Procedure 300.000 300.000
- Injection by Nurse 200.000 200.000
4 Medicines/Injection
- IVFD RL II 100.000 200.000
- Inji Hyoscine III 200.000 600.000
- Inj. Norages III 200.000 600.000
- Inj. omperazole II 200.000 400.000
- Inj. ceftriaxone II 200.000 400.000
- Inf. Paracetamol III 300.000 900.000
- Neurosanbe drip I 300.000 300.000
- Molagit X 100.000 100.000
- Ramolit V 70.000 70.000

5 Medical Devices & Consumables 300.000 300.000

6 Laboratory Test
- Complete blood count 800.000 800.000
- Ns1 1.000.000 1.000.000
- Widal 500.000 500.000
- IgG/IgM Anti Dengue 900.000 900.000
- Malaria 500.000 500.000
7 Hospitalization & Observation
- Observation with IV Drips 2-6 1.500.000 1.500.000
Hours
1 03/04/2023 Doctor fee
- Examination and consultation 550.000 550.000

Email: ops@mandalikamediccare.com Helpline: +62 82 339 545 830 www.mandalikamediccare.com

 • 24 Hours Medical Emergency
• On Call/Home Visit Service
• Vaccination & IV Hangover Cure
• Pharmacy & Laboratory
• Medical Evacuation Service
• Cashless Medical Service
• Guarantee Medical Bill

CV. BRAHMEDIKA UTAMA INDONESIA

2 Medical Procedure
- Infusion Procedure 300.000 300.000
- Injection by Nurse 200.000 200.000
3 Medicines/ Injection
- IVFD RL II 100.000 200.000
- Inj. Hyoscine III 200.000 600.000
- Inj. Norages III 200.000 600.000
- Inj. Omperazole II 200.000 400.000
- Inj. Ceftriaxone II 200.000 400.000
- Inf. Paracetamol III 300.000 900.000
- Neurosanbe drip I 300.000 300.000
- Moilagit X 100.000 100.000
4 Medical Devices & Consumables 350.000 350.000

5 Hospitalization & Observation

- Observation with IV Drips 13-24 3.000.000 3.000.000
Hours
1 04/04/2023 Doctor fee
- Examination and consultation 550.000 550.000

2 Medical Procedure
- Infusion Procedure 300.000 300.000
- Injection by Nurse 200.000 200.000
- Infusion Removal 200.000 200.000
3 Medicines/Injection
- Inj. Hyoscine II 200.000 400.000
- Inj. Norages II 200.000 400.000
- Inj. Omperazole I 200.000 200.000
- Inj. Ceftriaxone II 200.000 400.000
- Inf. Paracetamol II 300.000 600.000
- Helixime X 100.000 100.000
- Molagit X 100.000 100.000
- Scopma plus X 100.000 100.000
- Ramolit V 70.000 70.000
- Imboost X 200.000 200.000
4 Medical Devices & Consumables 200.000 200.000

5 Hospitalization & Observation

- Observation with IV Drips 13-24 3.000.000 3.000.000
Hours
Total 25.240.000
Amount
Billing to Amount
Eurocross Assistance IDR. 25.240.000

Email: ops@mandalikamediccare.com Helpline: +62 82 339 545 830 www.mandalikamediccare.com

 • 24 Hours Medical Emergency
• On Call/Home Visit Service
• Vaccination & IV Hangover Cure
• Pharmacy & Laboratory
• Medical Evacuation Service
• Cashless Medical Service
• Guarantee Medical Bill

CV. BRAHMEDIKA UTAMA INDONESIA

Remittance can be Transferred Trough :

Account Holder’s : CV. Brahmedika Utama Indonesia

Bank’s Name : Bank Mandiri KCP Mataram
Account Number : 161-00-0791757-3
SWIFT CODE : BMRIIDJA

Thanks & Best Regards

(ASMAH)

Email: ops@mandalikamediccare.com Helpline: +62 82 339 545 830 www.mandalikamediccare.com