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Payment Invoice

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Street Address
[City, ST ZIP Code]
Phone: +00 123456 Fax: 432 1231 3456

INVOICE



Invoice # [123]
Date: Nov 16, 2018
PATIENT DETAILS:
Name: Daniel
Age: 20
Address: 60-21/100, Smith street
Banglore, India
Phone: +91 12345 67890
Patient ID: PI675
Total Days: 10
Payment Type: Credit Card
1234 5678 9012 3456
Paypal
Services:
# Service Unit Cost Discount (%) Total
1 Chest X-ray $ 120 10 $ 108
2 Injury Operation $ 1000 20 $ 800
Total $ 1200
Tax $ 50
Discount $ 212
GRAND TOTAL $ 1038
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