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DUPLICATE
Invoice No. : D-B19-0019902/D-I19-0030733 Page : 1 of 3
Patient : WARREN EDWARD DELLOW Location : B002
Address : MAISON ARALSON ROOM 219 SANUR DENPASAR Date/Time : 01-MAR-2019 14:59
PRN : 00254102 Visit No. : D-V19-0021572
Payer : WARREN EDWARD DELLOW Admission Date : 26-FEB-2019 00:46
Discharge Date : 01-MAR-2019 15:00
Room/Class : 406-B01/STANDART 2
Date Item Code Description Quantity Amount(Rp.)

IP-Bed Charges
26/02/19 K001 BED CHARGE 1 1,700,000
27/02/19 K001 BED CHARGE 1 1,700,000
28/02/19 K001 BED CHARGE 1 1,700,000
01/03/19 K001 BED CHARGE 1 1,700,000
IP-Consultation
26/02/19 1600416 VISITE DR.SPESIALIS (DEWA AYU PUTRI SRI 1 750,000
MASYENI, INTERNIST, Ph.D)
27/02/19 1600416 VISITE DR.SPESIALIS (DEWA AYU PUTRI SRI 1 750,000
MASYENI, INTERNIST, Ph.D)
28/02/19 1600416 VISITE DR.SPESIALIS (DEWA AYU PUTRI SRI 1 750,000
MASYENI, INTERNIST, Ph.D)
01/03/19 1600416 VISITE DR.SPESIALIS (DEWA AYU PUTRI SRI 1 750,000
MASYENI, INTERNIST, Ph.D)
Lab Services
26/02/19 P115 DARAH LENGKAP 1 242,000
P120 AGD 1 630,000
6416 KULTUR SPUTUM 1 968,000
6447 PENGECATAN GRAM (MIKROSKOPIK) 1 216,000
6466 RESISTENSI 1 350,000
27/02/19 P120 AGD 1 630,000
28/02/19 P115 DARAH LENGKAP 1 242,000
P120 AGD 1 630,000
Medication
26/02/19 PH-CAI0256 NACL SANBE 100 ML DP 2 71,636
PH-CAI0139 SANMOL 100 ML INF 3 395,326
PH-CAI0137 RL SANBE 500 ML 4 151,232
PH-INJ0293 TERFACEF 1 G DI 2 910,047
PH-INJ0113 FLIXOTIDE 0.5 MG/2 ML NEB 2 84,637
PH-TAB0262 FLUIMUCIL 200 MG CAP 10 121,243
PH-CAI0115 NACL OTSU 25 ML 2 33,548
PH-INJ0328 VENTOLIN NEB 2 MG SOL 2 41,732
PH-TAB0491 MEZATRIN 250 MG TAB 6 187,315
PH-INJ0113 FLIXOTIDE 0.5 MG/2 ML NEB 3 126,955
PH-INJ0293 TERFACEF 1 G DI 4 1,820,095
PH-INJ0328 VENTOLIN NEB 2 MG SOL 3 62,599
PH-CAI0020 AQUA INJEKSI 25 ML OTSU 2 27,955
27/02/19 PH-SYR0090 FLUIMUCIL 75 ML DS 2 248,406
PH-CAI0020 AQUA INJEKSI 25 ML OTSU 2 27,955
PH-INJ0113 FLIXOTIDE 0.5 MG/2 ML NEB 2 84,637
PH-CAI0137 RL SANBE 500 ML 4 151,232
PH-INJ0293 TERFACEF 1 G DI 2 910,047
 KWITANSI
Bukti Pembayaran

DUPLICATE
Invoice No. : D-B19-0019902/D-I19-0030733 Page : 2 of 3
Patient : WARREN EDWARD DELLOW Location : B002
Address : MAISON ARALSON ROOM 219 SANUR DENPASAR Date/Time : 01-MAR-2019 14:59
PRN : 00254102 Visit No. : D-V19-0021572
Payer : WARREN EDWARD DELLOW Admission Date : 26-FEB-2019 00:46
Discharge Date : 01-MAR-2019 15:00
Room/Class : 406-B01/STANDART 2
Date Item Code Description Quantity Amount(Rp.)
PH-INJ0328 VENTOLIN NEB 2 MG SOL 2 41,732
28/02/19 PH-TAB0610 PROTEXIN NATURAL CARE CAPS 15 132,660
PH-INJ0293 TERFACEF 1 G DI 2 910,047
PH-INJ0113 FLIXOTIDE 0.5 MG/2 ML NEB 3 126,955
PH-CAI0137 RL SANBE 500 ML 2 75,616
PH-INJ0293 TERFACEF 1 G DI 3 1,365,071
PH-INJ0328 VENTOLIN NEB 2 MG SOL 3 62,599
01/03/19 PH-TAB1285 SPORETIK 200 MG TAB 5 307,885
PH-TAB0491 MEZATRIN 250 MG TAB 6 187,315
PH-CAI0020 AQUA INJEKSI 25 ML OTSU -2 -27,955
PH-CAI0020 AQUA INJEKSI 25 ML OTSU -2 -27,955
PH-INJ0113 FLIXOTIDE 0.5 MG/2 ML NEB -1 -42,318
PH-CAI0115 NACL OTSU 25 ML -1 -16,774
PH-CAI0137 RL SANBE 500 ML -1 -37,808
PH-CAI0139 SANMOL 100 ML INF -1 -131,775
PH-INJ0293 TERFACEF 1 G DI -2 -910,047
PH-INJ0328 VENTOLIN NEB 2 MG SOL -1 -20,866
PH-SLP0137 CENDO CENFRESH 0.6 MD TM 1 50,853
Miscellenous Fee
26/02/19 AD002 ADMINISTRASI RAWAT INAP (NON TINDAKAN) 1 750,000
OP-Consultation
26/02/19 1600303 EMERGENCY (PERIKSA DR.UMUM) 1 500,000
Other Services
26/02/19 1600433 PERAWATAN 1 800,000
27/02/19 1600433 PERAWATAN 2 1,600,000
28/02/19 1600433 PERAWATAN 1 800,000
01/03/19 1600433 PERAWATAN 1 800,000
Procedure Services
26/02/19 1600355 PASANG INFUS DEWASA 1 100,000
1600728 AFF INFUS 1 20,000
27/02/19 1600361 JASA INJEKSI(IM,IV,IC,SC) DI RUANGAN 1 50,000
01/03/19 1600688 OXYGEN 3 LITER/JAM 1 45,000
Retail
26/02/19 PH-ALK0313 SPUIT TERUMO 10 CC 2 32,280
PH-ALK0316 SPUIT TERUMO 5 CC 3 36,481
PH-ALK1067 JET NEB BESMED (DWS) 1 74,056
PH-ALK0313 SPUIT TERUMO 10 CC 3 48,420
27/02/19 PH-ALK0313 SPUIT TERUMO 10 CC 3 48,420
 KWITANSI
Bukti Pembayaran

DUPLICATE
Invoice No. : D-B19-0019902/D-I19-0030733 Page : 3 of 3
Patient : WARREN EDWARD DELLOW Location : B002
Address : MAISON ARALSON ROOM 219 SANUR DENPASAR Date/Time : 01-MAR-2019 14:59
PRN : 00254102 Visit No. : D-V19-0021572
Payer : WARREN EDWARD DELLOW Admission Date : 26-FEB-2019 00:46
Discharge Date : 01-MAR-2019 15:00
Room/Class : 406-B01/STANDART 2
Date Item Code Description Quantity Amount(Rp.)
------------------------
TOTAL : 26,914,489
------------------------
NET PAYABLE : 26,914,489
PAID BY :
Visa 2,513,000
AIG TRAVEL ASSIST MALAYSIA - C00018 24,401,489

Reference :
TWENTY-SIX MILLION NINE HUNDRED FOURTEEN THOUSAND FOUR HUNDRED EIGHTY-NINE

Denpasar, 01-MAR-2019

_________________________________________ DESIE
_______________________
Tanda tangan pasien/Penanggung Jawab Cashier
Patient Sign/Guarantor

______________________________________________________________________________________________________________________
1. Invoice ini merupakan tanda terima pembayaran resmi, setelah distempel oleh kasir
This is an official payment receipt, upon cashier stamp
2. Barang yang sudah dibeli tidak dapat ditukar/dikembalikan
Change or return after purchase are not allowed