Furlong Vision Correction Receipt

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Furlong Vision Correction Patient Services Department Suite 210 2640 East Main Street Springfield, IL 62701 United States Phone: (217) 555-7428

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Helping You See Life Clearly Thank You For Choosing Furlong Vision Correction

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Patient

Michael Anderson

Receipt #

FVC-684219

Phone

(555) 123-4567

Provider

Dr. Sarah Furlong

Procedure

LASIK Consultation

Patient ID

PT-472815

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Date: 6/10/2026 Time: 6:16:09 PM

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Initial Vision Assessment

$150.00

Corneal Mapping

$125.00

LASIK Consultation

$200.00

Follow-Up Evaluation

$75.00

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Subtotal$550.00

Medical Service Tax$0.00

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$550.00

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Payment MethodCredit Card (VISA)

Card Last 41234

Entry MethodCard Present

Authorization Code583921

StatusApproved

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1234567890

Please retain this receipt for insurance records. For questions regarding your visit, contact our office. Thank you for choosing Furlong Vision Correction!

CREATERECEIPT.com ha semplificato enormemente il mio processo di fatturazione.

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