| No: B-662 | Date: 14/06/2026 | ||
| Patient Name: SHIVAM JITUBHAI RAVAL | |||
| Age: 3M | M/F: MALE | ||
| Address:- KHERVA | |||
| D.O.A.: 09/06/2026 | D.O.D.: 14/06/2026 | ||
| Diagnosis: PNUMONIA WITH FEVER WITH VOMITING WITH DEHYDRATION | |||
| Particulars | Days | Unit Cost (Rs.) | Amount (Rs.) |
|---|---|---|---|
| TOTAL ( R/N/D )CHARGE | 6 | 3,500.00 | 21,000.00 |
| TOTAL | 21000.00 | ||
| IN WORDS : TWENTY-ONE THOUSAND RUPEES ONLY | |||
| Signature | |||