RECEIPT FORMAT

Receipt Format

The London Clinic

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Sold to

Inv Invoice Date

11/03/13

Receipt No Sold by RECEIPT Invoice to:

(XXX)

______________________

______________________

______________________

______________________

______________________

INVOICE Patient account number

Invoice date

Invoice number Admit / reg. date

Discharge date

No. of days

Third Party Ref

Authorisation Number



11/03/13

Patient:

(XXX)

______________________

______________________

______________________

______________________

______________________

Date

Description of Service Units

Total 11/03/13

Pathology

1

205.50

205.50

205.50

Amount Due £

The London Clinic

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Sold to

Inv Invoice Date

26/03/13

Receipt No Sold by RECEIPT

Invoice to:

(XXX)

______________________

______________________

______________________

______________________

______________________

INVOICE Patient account number

Invoice date

Invoice number Admit / reg. date

Discharge date

No. of days

Third Party Ref

Authorisation Number

26/03/13

Patient:

(XXX)

______________________

______________________

______________________

______________________

______________________

Date

Description of Service Units

Total 11/03/13

Biopsy

1

1015.00

1015.00



1015.00

Amount Due £ The London Clinic

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Sold to

Inv Invoice Date

11/03/13

Receipt No Sold by RECEIPT Invoice to:

(XXX)

______________________

______________________

______________________

______________________

______________________



INVOICE Patient account number

Invoice date

Invoice number Admit / reg. date

Discharge date

No. of days

Third Party Ref

Authorisation Number



11/03/13

Patient:

(XXX)

______________________

______________________

______________________

______________________

______________________

Date

Description of Service Units

Total 11/03/13

11/03/13

Ultrasound

Kidney

Abdomen

1

1

200.00

570.00

770.00

770.00

Amount Due £

The London Clinic

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Sold to

Inv Invoice Date

11/03/13

Receipt No Sold by RECEIPT Invoice to:

(XXX)

______________________

______________________

______________________

______________________

______________________

INVOICE Patient account number

Invoice date

Invoice number Admit / reg. date

Discharge date

No. of days

Third Party Ref

Authorisation Number

11/03/13

Patient:

(XXX)

______________________

______________________

______________________

______________________

______________________

Date

Description of Service Units

Total 11/03/13

CT Pulmonary Angiogram

1

1158.00

1158.00



1158.00

Amount Due £

The London Clinic

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

20 Devonshire Place, London WIG 6BW Tel: 020 7935 4444

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Fax: 020 7486 3782 REG. No. 307579 CHARITY No. 211136

Sold to

Inv Invoice Date

25/03/13

Receipt No Sold by RECEIPT Invoice to:

(XXX)

______________________

______________________

______________________

______________________

______________________

INVOICE Patient account number

Invoice date

Invoice number Admit / reg. date

Discharge date

No. of days

Third ...