SKDC Template
SKDC Template
NAME OF PATIENT
No GL NO DATE APPLIED REQ. NO. (Last Name, First Name, PAYABLE TO HOSPITAL / DIALYSIS CENTER
Middle Name)
Total amount
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION
DIALYSIS INJECTION