Beruflich Dokumente
Kultur Dokumente
Patient Name: __________________________________ Age: _______ Date & Time Admitted: _______________________________
Address: __________________________________________________ Date & Time Discharged: _____________________________
Final Diagnosis: ___________________________________________ First Case Rate: ____________________________________
Other Diagnosis: 1. _______________________________________ Second Case Rate: __________________________________
2. _______________________________________
3. _______________________________________
SUMMARY OF FEES
Subtotal ₱ ₱ ₱ ₱ ₱ ₱ ₱
Professional Fee/s
1. ERLINDA VITAL
2.
3.
Subtotal ₱ ₱ ₱ ₱ ₱ ₱ ₱
Total ₱ ₱ ₱ ₱ ₱ ₱ ₱
NOTE:
1. Form out the form legibly
2. The member/patient/authorized representative should not sign a blank SOA
3. Printed copy of SOA or its equivalent should be free of charge