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Live -Vorschau
10/06/2026
Proposal Treatment
Dr. John Doe
123 Main St, Anytown, USA
MAURA
123 Main St, Anytown, USA
AUSWEIS : AF54hh
| Phase | Datumsplan | Appt | Anbieter | Service | Tth | Surfen | Gebühr | Ins | Klopfen |
| 1 | D20261006 | D20261006 | DJO | Comprehensive ORAL EVALUSA | 16 | $200 | $50 | $20 | |
| Zwischensumme | $200.00 | $50.00 | $20.00 | ||||||
| Steuer | $0.00 |
Insurance Coverage is only an estimation. A guarantor is responsible for all treatment not covered by insurance. The Above prices are valid for 60 days.
Insgesamt vorgeschlagen
$200.00
Gesamt abgeschlossen
$5000
Total akzeptiert
$5000
Vorgeschlagene Versicherung
$50.00
I have been advised of the treatment recommendation above, I am aware delaying treatment may lead to more extensive and costly treatment. A new exam may be required after 60 days
Unterschrift des Patienten oder Erziehungsberechtigten________________________________________Datum
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