Summary Outpatient Statement Of Account

Run Datetime : 02/12/2024 08:33:S6

Patient Name: Mollanida, Meriam Odtojan
PARTICULARS DEBIT CREDIT
Sex/Age: Female/46
LABORATORY y
Medicine and Chemistry 6,050.00
Address: Purok
X-ray Chest PA2 Pulong Sta Cruz Santa Rosa Laguna 5,860.88
CT Scan 3,585.70
4,574.69
PHARMACY
Recovery Room
10,500.00
20,071.27 9,571.27
BALANCE DUE 9,571.27
Transaction Date: 02/12/2024

I hereby acknowledge that the above services were actually

received and rendered while admitted in this hospital.
Signature
CAS PERMIT NO. ! 0109-03300003
DATE ISSUED: January 28,2024