Recibo de hospital
Para ver la vista previa en vivo Haga clic aquí
Vista previa en vivo
07/07/2026
Proposal Treatment
Dr. John Doe
123 Main St, Anytown, USA
MAURA
123 Main St, Anytown, USA
IDENTIFICACIÓN : AF54hh
| Fase | Plan de fecha | Cita | Proveedor | Servicio | Tth | Navegar | Tarifa | Informes | Palmadita |
| 1 | D20260707 | D20260707 | DJO | Comprehensive ORAL EVALUSA | 16 | $200 | $50 | $20 | |
| Total parcial | $0.00 | $0.00 | $0.00 | ||||||
| Impuesto | $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.
Total propuesto
$0.00
Total completado
$5000
Total aceptado
$5000
Seguro propuesto
$0.00
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
La firma del paciente o del tutor________________________________________Fecha
Current Dental Terminology(CDT) © American Dental Association(ADA). All Rights Reserved