Ricevuta ospedaliera
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Anteprima dal vivo
07/09/2026
Proposal Treatment
Dr. John Doe
123 Main St, Anytown, USA
MAURA
123 Main St, Anytown, USA
ID : AF54hh
| Fase | Piano di data | Appt | Fornitore | Servizio | TTH | Navigare | Tassa | Ins | Pat |
| 1 | D20260709 | D20260709 | DJO | Comprehensive ORAL EVALUSA | 16 | $200 | $50 | $20 | |
| Subtotale | $0.00 | $0.00 | $0.00 | ||||||
| Tassare | $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.
Totale proposto
$0.00
Totale completato
$5000
Totale accettato
$5000
Assicurazione proposta
$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
Firma del paziente o tutore________________________________________Data
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