Free Medical Receipt Format Template
Medical Receipt Format
ISSUED BY: [YOUR NAME], [YOUR COMPANY NAME]
DATE: [DATE OF RECEIPT]
RECEIPT NO.: [RECEIPT NUMBER]
PATIENT DETAILS
-
NAME: [PATIENT NAME]
-
CONTACT: [PATIENT CONTACT INFORMATION]
BILLING SUMMARY
|
DESCRIPTION |
AMOUNT (USD) |
|---|---|
|
CONSULTATION FEE |
$[AMOUNT] |
|
MEDICATION |
$[AMOUNT] |
|
OTHER CHARGES |
$[AMOUNT] |
|
TOTAL AMOUNT |
$[AMOUNT] |
PAYMENT RECEIVED: $[AMOUNT]
BALANCE DUE: $[AMOUNT]
NOTES: [OPTIONAL COMMENTS]
SIGNATURE: ______________________
