| No: B-636 | Date: 10/05/2026 | ||
| Patient Name: DHAVAL BALVANT KAPDI | |||
| Age: 1.5Y | M/F: MALE | ||
| Address:- MOJRU | |||
| D.O.A.: 07/05/2026 | D.O.D.: 10/05/2026 | ||
| Diagnosis: CONVERSION | |||
| Particulars | Days | Unit Cost (Rs.) | Amount (Rs.) |
|---|---|---|---|
| TOTAL ( R/N/D )CHARGE | 4 | 3,000.00 | 12,000.00 |
| TOTAL | 12000.00 | ||
| IN WORDS : TWELVE THOUSAND RUPEES ONLY | |||
| Signature | |||