| TO: | BERGSTEIN, AKI | DATE: | 2025-06-29 | |||
| ADDRESS: | STO. NIÑO, 1820, MARIKINA CITY | OSCA/PWD ID NO.: | N/A | |||
| SIGNATURE: | N/A |
| QTY | UNIT | DESCRIPTION | UNIT PRICE | AMOUNT |
| 1 | SET | CONSULT AND PROCEDURE | 1500 | 1500 |
| DR. HALIMBAWA, USBONG | ||||
| 1 | PC | X-RAY EXAM | 400 | 400 |
| 1 | PC | LONGBONE ARM SLING BLUE | 250 | 250 |
| ADULT -LARGE | ||||
| 2150 |
| BY: | RECEIVED BY: |
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| SYSON, MICHAEL B. | _________________ |
| COUNT | BODY LOCATION | TYPE | PRICE | SC/PWD PRICE |