MEDICAL BILL RECEIPT

Receipt Number: 06825

Date: 30/9/23
Name of Medical institution: INTEGRIS HEALTH COMMUNITY HOSPITAL
Practitioner Name: oluwasegun
License Number: 00078268
Address: 300 s Rockwell ave
City/State/ZIP: ok 73128

Patient Information:
Name:toheeb
Street Address:iliasu olamide street
City/State/ZIP 97835

Code Description of Qty Rate Line Total

Services/Medicine/Products ($)
337 Cholesterol High 2.5

Subtotal: $________
Tax Rate (__):_________________
Total: $_________________
Amount Paid: $_________________
Payment Method: _________________
Card/Check No.: _________________

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