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Claim Stub - Optical Clinic

If your patient/client is purchasing something but you cannot give it immediately, you can ask for downpayment and give this claim stub. Indicate at the back of each stub the total purchase price, downpayment, and balance if there's any.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
734 views2 pages

Claim Stub - Optical Clinic

If your patient/client is purchasing something but you cannot give it immediately, you can ask for downpayment and give this claim stub. Indicate at the back of each stub the total purchase price, downpayment, and balance if there's any.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical

n Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Claim Stub Claim Stub Claim Stub Claim Stub
Rx #: Rx #: Rx #: Rx #:
Date:_____________ Date:_____________ Date:_____________ Date:_____________
Name:___________________ Name:___________________ Name:___________________ Name:___________________
_ _ _ _
Remarks:________________ Remarks:________________ Remarks:________________ Remarks:________________
_ _ _ _
________________________ ________________________ ________________________ ________________________
___ ___ ___ ___
Due Due Due Due
date:_________________ date:_________________ date:_________________ date:_________________
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison
Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison
Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic
Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison
Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic Kyrie Eleison Optical Clinic

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