Payment Invoice
Street Address
[City, ST ZIP Code]
Phone: +00 123456 Fax: 432 1231 3456
INVOICE
Invoice # [123]
Date: Nov 16, 2018
PATIENT DETAILS:
Name: DanielAge: 20
Address: 60-21/100, Smith street
Banglore, India
Phone: +91 12345 67890
Patient ID: PI675
Total Days: 10
Payment Type: Credit Card
1234 5678 9012 3456
Paypal
Total Days: 10
Payment Type: Credit Card
1234 5678 9012 3456
Paypal
Services:
| # | Service | Unit Cost | Discount (%) | Total |
|---|---|---|---|---|
| 1 | Chest X-ray | $ 120 | 10 | $ 108 |
| 2 | Injury Operation | $ 1000 | 20 | $ 800 |
| Total | $ 1200 |
| Tax | $ 50 |
| Discount | $ 212 |
| GRAND TOTAL | $ 1038 |
Note:
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Signature
Signature