Intermediate Bill (Report)

Name : Mrs.A M DARSHIKA DANANJANI ABEYKOON Bill No :

Address : , JA-ELA - , Bill Date :
IP NO : WTL-IPV-2409-14960
Patient ID : PAT02572772
Contact No : 94763829988 Bed No : 216
Gender : FEMALE Date of Admission : 02-09-2024 10:28
Payor Type : Mobizz Elite (PVT) Ltd Date of Surgery :

Consultant Name : Dr Deepal Attanayake

Specialty : Neuro Surgeon

BedName Bed Type No Of Days In Time Out Time

216 EXECUTIVE 1 02-09-2024 10:31 AM 03-09-2024 03:55 PM

Order Date Code/Name/Services Rendered Qty Unit Rate Amount (LKR)

Admission Charges
02/09/2024 10:53 AM Admission fee 1 15000.00 15,000.00
15,000.00

Bed Rentals
02/09/2024 10:31 AM EXECUTIVE 1 19500.00 23,010.00
23,010.00

Consumable Charges
ISSUES
02/09/2024 11:00 AM SYRINGE 5 CC TERUMO 3 247.18 741.54
02/09/2024 11:00 AM EXAMINATION GLOVES POWDER FREE SMALL 10 81.69 816.95
02/09/2024 11:00 AM MEDICAL TRANSPARENT IV DRESSING 1 498.75 498.75
02/09/2024 11:00 AM ALCOHOL PAD 2 22.45 44.90
02/09/2024 11:00 AM SYRINGE 3 CC TERUMO 3 201.28 603.83
02/09/2024 11:00 AM IV CANNULA VASOFIX 20G BBRAUN 1 1304.17 1,304.17
02/09/2024 01:54 PM SYRINGE 3 CC TERUMO 1 201.28 201.28
02/09/2024 01:54 PM SYRINGE 10 CC TERUMO 1 291.91 291.91
02/09/2024 01:54 PM WATER FOR INJECTION 10ML (STERILE WATER) 2 55.39 110.79
03/09/2024 11:46 AM GAUZE SWABS PLAIN 4" X 4" 10 77.21 772.07
5,386.19

Food & Beverages

Beverages
03/09/2024 08:04 AM Cup of Tea (EXTRA) 1 210.00 210.00
210.00

Kitchen
03/09/2024 08:04 AM WATER AMERICAN WATER 1L 1 100.00 100.00
100.00

Laboratory Charges
Biochemistry
02/09/2024 11:00 AM Creatinine- Serum 1 1460.00 1,460.00
03/09/2024 12:55 PM C-Reactive Protein (CRP) 1 2160.00 2,160.00
Profile
03/09/2024 12:55 PM Full Blood count (FBC) 1 400.00 400.00
4,020.00

Linen Charges

Printed Date 03-09-2024 15:55 PM Page 1 of 4

 Name : Mrs.A M DARSHIKA DANANJANI ABEYKOON Bill No :
Address : , JA-ELA - , Bill Date :
IP NO : WTL-IPV-2409-14960
Patient ID : PAT02572772
Contact No : 94763829988 Bed No : 216
Gender : FEMALE Date of Admission : 02-09-2024 10:28
Payor Type : Mobizz Elite (PVT) Ltd Date of Surgery :

Consultant Name : Dr Deepal Attanayake

Specialty : Neuro Surgeon

BedName Bed Type No Of Days In Time Out Time

216 EXECUTIVE 1 02-09-2024 10:31 AM 03-09-2024 03:55 PM

Order Date Code/Name/Services Rendered Qty Unit Rate Amount (LKR)

02/09/2024 10:31 AM Linen Charges 1 1750.00 1,750.00

1,750.00

Medical Officer Charges

02/09/2024 10:31 AM Resident Medical Officer's charge 1 8800.00 8,800.00
8,800.00

Medication Charges
ISSUES
02/09/2024 01:54 PM HYDROCORT SODIUM SUCC 100MG INJECTION 2 391.00 782.00
(HYDROCORTISONE)
02/09/2024 10:40 PM HCQS 200MG TABLET (HYDROXYCHLOROQUINE) 4 128.08 512.34
02/09/2024 10:40 PM NEXITO 10MG TABLET (ESCITALOPRAM) 2 103.69 207.39
02/09/2024 10:40 PM BACLON 10MG TABLET (BACLOFEN) 2 59.21 118.42
02/09/2024 10:40 PM GABA 100 MG TABLET (GABAPENTIN) 2 33.27 66.54
02/09/2024 10:40 PM PANADEINE 500MG TABLET (PARACETAMOL + CODEINE) 6 28.05 168.30
02/09/2024 10:40 PM DVAC 60000IU TABLET (CHOLECALCIFEROL + VIT K) 1 326.40 326.40
02/09/2024 10:40 PM FEXET 180MG TABLET (FEXOFENADINE) 2 80.84 161.68
02/09/2024 10:40 PM MULAX 2MG TABLET (TIZANIDINE) 2 118.24 236.48
02/09/2024 10:40 PM ATERONOM CAPSULE (THE TOMATO PILL) 2 418.27 836.53
02/09/2024 10:40 PM CELOX R 200MG CAPSULE (CELECOXIB) 4 70.35 281.42
02/09/2024 10:40 PM Cartigen Cream 30G (GLUCOSAMINE) 1 2432.70 2,432.70
03/09/2024 12:19 PM MULAX 2MG TABLET (TIZANIDINE) 7 118.24 827.68
03/09/2024 12:19 PM GABA 100 MG TABLET (GABAPENTIN) 7 33.27 232.89
03/09/2024 12:19 PM HCQS 200MG TABLET (HYDROXYCHLOROQUINE) 14 128.08 1,793.17
03/09/2024 12:19 PM CARBATOL CR 200MG TABLET (CARBAMEZAPINE) 7 40.48 283.36
03/09/2024 12:19 PM ATERONOM CAPSULE (THE TOMATO PILL) 7 418.27 2,927.86
03/09/2024 12:19 PM CELOX R 200MG CAPSULE (CELECOXIB) 14 70.35 984.96
03/09/2024 12:19 PM NEXITO 10MG TABLET (ESCITALOPRAM) 7 103.69 725.86
03/09/2024 12:19 PM FEXET 180MG TABLET (FEXOFENADINE) 7 80.84 565.88
03/09/2024 12:19 PM BACLON 10MG TABLET (BACLOFEN) 7 59.21 414.47
03/09/2024 12:19 PM Cartigen Cream 30G (GLUCOSAMINE) 1 2136.90 2,136.90
03/09/2024 12:19 PM PANADEINE 500MG TABLET (PARACETAMOL + CODEINE) 28 28.05 785.40
03/09/2024 02:09 PM DVAC 60000IU TABLET (CHOLECALCIFEROL + VIT K) 1 326.40 326.40
18,135.03

Nursing Care Charges

02/09/2024 10:31 AM General Nursing Care 1 8800.00 8,800.00
8,800.00

Procedure Charges
02/09/2024 10:31 AM Medical Administration Charges 1 2420.00 2,420.00
02/09/2024 10:53 AM Sterilization charges 1 2000.00 2,000.00

Printed Date 03-09-2024 15:55 PM Page 2 of 4

 Name : Mrs.A M DARSHIKA DANANJANI ABEYKOON Bill No :
Address : , JA-ELA - , Bill Date :
IP NO : WTL-IPV-2409-14960
Patient ID : PAT02572772
Contact No : 94763829988 Bed No : 216
Gender : FEMALE Date of Admission : 02-09-2024 10:28
Payor Type : Mobizz Elite (PVT) Ltd Date of Surgery :

Consultant Name : Dr Deepal Attanayake

Specialty : Neuro Surgeon

BedName Bed Type No Of Days In Time Out Time

216 EXECUTIVE 1 02-09-2024 10:31 AM 03-09-2024 03:55 PM

Order Date Code/Name/Services Rendered Qty Unit Rate Amount (LKR)

4,420.00

Professional Fee
02/09/2024 11:47 PM Dr. Padmasiri Bandaranayake 1 13000.00 13,000.00
03/09/2024 11:40 AM DR Wasantha Sathkorala 1 5000.00 5,000.00
03/09/2024 11:42 AM Dr. Deepal Attanayake 1 15000.00 15,000.00
33,000.00

Radiology Services
MRI
02/09/2024 11:47 PM MRI Scan Brain 1 41100.00 41,100.00
02/09/2024 11:47 PM MRI Contrast 1 19800.00 19,800.00
02/09/2024 11:47 PM MRI Backache Protocol 1 44300.00 44,300.00
US Scan
03/09/2024 07:10 AM US Scan Abdomen/Kub 1 4400.00 4,400.00
109,600.00

Printed Date 03-09-2024 15:55 PM Page 3 of 4

 Total Bill Amount (LKR) 232,231.22
Mobizz Elite (PVT) Ltd 212,659.11

Deposit(-) 0.00
Discount(-) 19,572.11
Net payable : 212,659.11

Bill Transaction Details :

Note :
This is not a final bill. Charges may vary once the final bill is prepared. Current outstanding as per the
service offered by the hospital without the final consultant's charges at the time of issue shown here.
kindly contact the billing department extension on390 for any clarification.
Kindly notice to make a minimum payment of Rs.................... considering total outstanding amount
by ........./........./......... Am/Pm
NAME : Sayeeda Amsa
DESIGNATION : Billing In charge
WORK : 0117-888888(Ext 390/ 028) Imesha Dharmasiri
MOBILE : 0707898818
EMAIL : [email protected] PREPARED BY CASHIER :

PATIENT/ATTENDANT SIGN.