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08/23/2025
Proposal Treatment
Dr. John Doe
123 Main St, Anytown, USA
MAURA
123 Main St, Anytown, USA
EU IA : AF54hh
| Fase | Plano de data | APPT | Provedor | Serviço | TTH | Surf | Taxa | Ins | Pat |
| 1 | 08/22/2025 | 08/22/2025 | DJO | Comprehensive ORAL EVALUSA | 16 | $200 | $50 | $20 | |
| Subtotal | $0.00 | $0.00 | $0.00 | ||||||
| Imposto | $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 proposto
$0.00
Total concluído
$5000
Total aceito
$5000
Seguro proposto
$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
Paciente ou assinatura do guardião________________________________________Data
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