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08/23/2025
Proposal Treatment
Dr. John Doe
123 Main St, Anytown, USA
MAURA
123 Main St, Anytown, USA
IDENTIFIANT : AF54hh
| Phase | Datte | Appt | Fournisseur | Service | Tth | Surf | Frais | Insouffisants | Tapoter |
| 1 | 08/22/2025 | 08/22/2025 | DJO | Comprehensive ORAL EVALUSA | 16 | $200 | $50 | $20 | |
| Total | $0.00 | $0.00 | $0.00 | ||||||
| Impôt | $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 proposé
$0.00
Total terminé
$5000
Total accepté
$5000
Assurance proposée
$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
Signature du patient ou du tuteur________________________________________Date
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