RECEIPT (Emergency)

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RECEIPT (Emergency)

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BHAKTI RAHAYU

MEDICAL CLUB
Jalan Gatot Subroto II No. 11 Denpasar-Bali
Tlp. 0361 430270, 430245, 7451875
Fax. 0361 263371, 430833

RECEIPT
NO. _____________________
Receive with thank from __________________________________________________________________
______________________________________________________________________________________
In settlement of the following items
1 Doctors fee ________________________ Rp.________________________________________
2 Medicine Injection _______________________ Rp._________________________________________
3 Laboratory Test ________________________ Rp._________________________________________
4 X ray ________________________ Rp._________________________________________
5 Other ________________________ Rp._________________________________________
Kind of illness ____________________________________________________________________
Medication ____________________________________________________________________

Guest, Bali, ____________________

Rp. ________________________________
( ) ( )

BHAKTI RAHAYU
MEDICAL CLUB
Jalan Gatot Subroto II No. 11 Denpasar-Bali
Tlp. 0361 430270, 430245, 7451875
Fax. 0361 263371, 430833

Guest, Bali, ____________________

Rp. ________________________________
( ) ( )

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