GSTIN : 09AAACI2398N2ZZ

In Patient Bill - Bill of Supply Reference No :

Name : Mr. PA N K A J K U M A R Age: 39Yr 11Mth 27Days
UHID : APD2.0000247622
SAMADHIYA Sex: Male

Guardian : NOT CAPTURED

*APD2.0000247622*
Name
Address : PAHARI CHUNGI CHIRGAON Jhansi Uttar Pradesh IP Number: NOIIP107968
India, Cell No:91-9821661053
*NOIIP107968*
Pan Number:

Doctor Name : DR. VIKRAM BHARDWAJ Bill No : NOI-ICS-27146

Speciality : ENT
SEMI-PVT TRIPLE BED
Date : 17-Oct-2024 Time : 13:03:39
Ward Name :
Bed No : 1206(SEMI-PVT TRIPLE BED )
*NOI-ICS-27146*
Billing Account Type : CASH Admission Date : 15-Oct-2024 10:06:07 am

Discharge Date : 17-Oct-2024 11:11:07 am

SL. No Service Amount(INR)

1 Consultation(999311 ) 4,050.00
2 Hospital services (others)(999311 ) 150.00
3 Invasive Procedures(999311 ) 57,450.00
4 Investigations(999311 ) 1,150.00
5 Medical Administration(999311 ) 240.00
6 Medical Services(999311 ) 1,700.00
7 Nutritional and Functional Assessment Charges(999311 ) 820.00
8 OT Charges(999311 ) 51,705.00
9 OT Consumables(999311 ) 1,818.95
10 Professional Charges(999311 ) 19,148.09
11 Room Rent(999311 ) 7,800.00
12 Ward consumables(OT stores)(999311 ) 3,700.00
13 Ward Pharmacy(999311 ) 11,799.81

Page 1 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146

Service Amount 161,532.00

Total Discount 0.00

Service Amount After Discount (Bill of Supply) 161,532.00

Other Information :
Bill of Supply : NOI-ICS-27146 161,532.00
Tax Invoice : 0.00
Total Payable Amount 161,532.00

Deposit (14314249,14304016,14304007,14304000 (Cash:0.00, NonCash:161,532.00) 161,532.00

Refunded )() 0.00
Net Payable 0.00
Bill amount in words : Rupees Rupees Only

No Tax is Payable on Reverse Charge Basis

Mr. ASHEESH NEGI Mr. ASHEESH NEGI

Generated By Cashier
Online Payment access- https://pay.apollohospitals.com

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 2 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146

SI.No Service Service Name Start Date End Date Dr Name Qty Amount(INR)
Code ( Order No. )
Consultation(999311 ) 4,050.00
15-Oct-2024
Consultation 2,700.00
1 2117 IP Visit Charges 15-Oct-2024 DR. VIKRAM 1.00 1,350.00
0:00.00 BHARDWAJ(ENT )
2 2117 IP Visit Charges 15-Oct-2024 DR. VIKRAM 1.00 1,350.00
0:00.00 BHARDWAJ(ENT )
16-Oct-2024
Consultation 1,350.00
1 2117 IP Visit Charges 16-Oct-2024 DR. VIKRAM 1.00 1,350.00
0:00.00 BHARDWAJ(ENT )
Hospital services (others)(999311 ) 150.00
16-Oct-2024
F and B Room Service 150.00
1 2116 Patient Dietary 16-Oct-2024 1.00 150.00
(796429 ) 22:04.58
Invasive Procedures(999311 ) 57,450.00
15-Oct-2024
Ear Nose and Throat 57,450.00
1 24229 SEPTOPLASTY 15-Oct-2024 (DR. VIKRAM 1.00 4,750.00
(260760 ) 15:46.00 BHARDWAJ - ENT )
2 85532 TERBINOPLASTY (BILATERAL) 15-Oct-2024 (DR. VIKRAM 1.00 52,700.00
(260760 ) 15:47.00 BHARDWAJ - ENT )
Investigations(999311 ) 1,150.00
15-Oct-2024
BioChemistry 470.00
1 376 SODIUM (NA+)-SERUM 15-Oct-2024 1.00 470.00
(4904782 ) 10:33.51
X Ray 680.00
2 1252 X-RAY CHEST PA 15-Oct-2024 DR. VIKRAM 1.00 680.00
(4611717 ) 11:19.00 BHARDWAJ(ENT )
Medical Administration(999311 ) 240.00
15-Oct-2024
Medical Records 240.00
1 2114 Medical Records 15-Oct-2024 1.00 240.00
10:06.10
Medical Services(999311 ) 1,700.00
Medical 1,700.00
1 1077592 Hospital Services and Treatment Monitoring 2.00 1,700.00
and Management Charges(AC-MULTI BED )

Nutritional and Functional Assessment Charges(999311 ) 820.00

15-Oct-2024
Food and Beverages 410.00
1 1087353 Patient Diet Charges 15-Oct-2024 1.00 410.00
10:06.07
16-Oct-2024
Food and Beverages 410.00

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 3 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146
1 1087353 Patient Diet Charges 16-Oct-2024 1.00 410.00
10:06.07
OT Charges(999311 ) 51,705.00
15-Oct-2024
Operation Theatre 51,705.00
1 2103 Operation Theatre Charges 15-Oct-2024 15-Oct-2024 Mr. CAPS 1.00 47,430.00
(260760 ) 12:55.00 14:00.00
2 2103 Operation Theatre Charges 15-Oct-2024 15-Oct-2024 Mr. CAPS 1.00 4,275.00
(260760 ) 12:55.00 14:00.00
OT Consumables(999311 ) 1,818.95
15-Oct-2024
Operation Theatre 1,818.95
1 7470000 FENTANYL 2 ML 15-Oct-2024 1.00 46.95
0082753 (PMIS02046712 ) 18:15.47
2 1078500 NASAL DRESSING WITH STRING (8.0 15-Oct-2024 2.00 1,100.00
0000229 X1.5X2.0)CM CAT NO. E7181 MAKE - 18:15.47
177 OSSEOUS
(PMIS02046712 )
3 1086200 SURGIWEAR ( TROLLY COVER) D-304 15-Oct-2024 1.00 85.00
0000800 -S&S# 18:15.47
46 (PMIS02046712 )
4 1011700 VICRYL PLUS ABSORBABLE SURGICAL 15-Oct-2024 1.00 587.00
0000262 SUTURE USP BOX OF 12 FOILS SIZE 4 0 18:15.47
0491 CAT. NO. VP2304 MAKE JOHNSON AND
JOHNSON.
(PMIS02046712 )
Professional Charges(999311 ) 19,148.09
15-Oct-2024
Anaesthesiology 19,148.09
1 2122 Anaesthesiologist Fees 15-Oct-2024 Mr. CAPS 1.00 1,583.18
(260760 ) 12:55.00 (ANAESTHESIOLO
GY )
2 2122 Anaesthesiologist Fees 15-Oct-2024 Mr. CAPS 1.00 17,564.91
(260760 ) 12:55.00 (ANAESTHESIOLO
GY )
Room Rent(999311 ) 7,800.00
Wards Others 7,800.00
1 2127 ROOM RENT(AC-MULTI BED ) 2.00 7,800.00

Ward consumables(OT stores)(999311 ) 3,700.00

15-Oct-2024
Treatment Room 3,700.00
1 86358 DESFLURANE 15-Oct-2024 80.00 3,200.00
(1192677 ) 13:16.56
2 51711 SODALIME 15-Oct-2024 10.00 500.00
(1192677 ) 13:16.56
Ward Pharmacy(999311 ) 11,799.81
15-Oct-2024
10,627.56
1 47945 ACCU-CHEK SAFE-T-PRO UNO ## ( 15-Oct-2024 1.00 15.00
HSN:90183990 ) 12:05.04
(PMIS0215798955 )

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 4 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146
2 31188 ADVENT 1.2GM INJ ( HSN:30049087 ) 15-Oct-2024 2.00 315.02
(PMIS0215800266 ) 18:00.55
3 101213 AEROTEK NEBULIZER ACCESSORIES KIT 15-Oct-2024 1.00 690.00
ADULT SH-2426S (ROMSONS) 12:05.04
(PMIS0215798955 )
4 37917 ARTIFLEX BANDAGE 10CM X 3M (3M) 15-Oct-2024 1.00 212.00
(HSN:30051090 ) 18:07.44
(PMIN0215887196 )
5 99706 BAROCID 40MG INJ 15-Oct-2024 1.00 56.50
(PMIS0215798880 ) 11:41.10
6 99706 BAROCID 40MG INJ 15-Oct-2024 2.00 113.00
(PMIS0215800266 ) 18:00.55
7 94771 B.BRAUNOMOL IV 1000MG/100ML INFUSION 15-Oct-2024 1.00 595.00
(PMIN0215887196 ) 18:07.44
8 30813 BUDECORT 0.5MG RESPULES 2ML ( 15-Oct-2024 1.00 26.65
HSN:30049099 ) 11:41.10
(PMIS0215798880 )
9 20106 CATHETER MOUNT (INTER SURGICALS) 15-Oct-2024 1.00 525.00
(PMIN0215886308 ) 14:34.27
10 31670 CIPLOX D EYE DROPS 10ML(HSN:30042013 15-Oct-2024 1.00 26.55
) 14:34.27
(PMIN0215886308 )
11 74603 CISBLOK 10MG/5ML INJ(HSN:30049099 ) 15-Oct-2024 1.00 699.30
(PMIN0215886308 ) 14:34.27
12 3036 DC ALCOHOL SWAB 100S ## ( 15-Oct-2024 1.00 2.20
HSN:90189099 ) 12:05.04
(PMIS0215798955 )
13 71607 DC GAUZE SWABS 5X5CM 12 PLY ( 15-Oct-2024 1.00 30.00
HSN:30051090 ) 12:05.04
(PMIS0215798955 )
14 101731 DC PREMIUM WET WIPES 10S 15-Oct-2024 1.00 350.00
(PMIS0215800277 ) 17:59.02
15 50420 DYNAPAR AQ INJ 1ML ( HSN:30049066 ) 15-Oct-2024 2.00 79.20
(PMIS0215800266 ) 18:00.55
16 18367 ENDOTRACHEL TUBE CUF 08 (PORTEX) 15-Oct-2024 1.00 257.00
(HSN:90183990 ) 14:34.27
(PMIN0215886308 )
17 93852 ENLIVA P/F NITRILE EXAMINATION 15-Oct-2024 10.00 200.00
GLOVES-M 100S (WADI) ( HSN:30049091 ) 17:59.02
(PMIS0215800277 )
18 20410 GAUZE PIECES 10CM X 10CM # ( 15-Oct-2024 1.00 65.00
HSN:30051090 ) 12:05.04
(PMIS0215798955 )
19 20410 GAUZE PIECES 10CM X 10CM 15-Oct-2024 5.00 325.00
#(HSN:30051090 ) 18:07.44
(PMIN0215887196 )
20 61404 HME FILTER (A) 1841-000(HSN:90183990 ) 15-Oct-2024 1.00 445.00
(PMIN0215886308 ) 14:34.27
21 80103 INTRAFIX SAFESET B.C.V. 180CM 15-Oct-2024 1.00 408.00
(B.BRAUN)(HSN:90183990 ) 14:34.27
(PMIN0215886308 )

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 5 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146
22 70775 KABILYTE 500ML FREEFLEX 15-Oct-2024 2.00 686.00
POUCH(HSN:30049099 ) 14:34.27
(PMIN0215886308 )
23 34104 LEVOFLOX 100ML IV 15-Oct-2024 1.00 251.22
(PMIN0215886308 ) 14:34.27
24 33862 LEVOLIN 0.63MG RESPULES ( 15-Oct-2024 1.00 7.16
HSN:30049091 ) 11:41.10
(PMIS0215798880 )
25 33940 LOX 2% ADRENALINE 30ML 15-Oct-2024 1.00 35.27
INJ(HSN:30039034 ) 18:07.44
(PMIN0215887196 )
26 61452 MICROPORE S-2 INCH# 15-Oct-2024 1.00 188.00
(PMIN0215886308 ) 14:34.27
27 36375 MYO-PYROLATE IV INJ(HSN:30049099 ) 15-Oct-2024 1.00 123.70
(PMIN0215886308 ) 14:34.27
28 59044 NEEDLES 18 X 1.1/2G (B.D)# 15-Oct-2024 10.00 65.00
(PMIN0215886308 ) 14:34.27
29 48882 NEOROF 20ML INJ(HSN:30049099 ) 15-Oct-2024 1.00 145.50
(PMIN0215886308 ) 14:34.27
30 66346 N.S 100ML (PLASTIC FRESENIUS) ( 15-Oct-2024 3.00 141.27
HSN:25010020 ) 18:00.55
(PMIS0215800266 )
31 91809 OMNIVAN 10ML SYRINGE (B.BRAUN) ( 15-Oct-2024 1.00 28.60
HSN:30049099 ) 12:05.04
(PMIS0215798955 )
32 91809 OMNIVAN 10ML SYRINGE (B.BRAUN) ( 15-Oct-2024 5.00 143.00
HSN:30049099 ) 17:59.02
(PMIS0215800277 )
33 91809 OMNIVAN 10ML SYRINGE (B.BRAUN) 15-Oct-2024 1.00 28.60
(HSN:30049099 ) 18:07.44
(PMIN0215887196 )
34 91810 OMNIVAN 2ML SYRINGE (B.BRAUN) 15-Oct-2024 5.00 66.00
(HSN:30049099 ) 14:34.27
(PMIN0215886308 )
35 91811 OMNIVAN 5ML SYRINGE (B.BRAUN) 15-Oct-2024 5.00 90.75
(PMIN0215886308 ) 14:34.27
36 91811 OMNIVAN 5ML SYRINGE (B.BRAUN) ( 15-Oct-2024 1.00 18.15
HSN:90183100 ) 12:05.04
(PMIS0215798955 )
37 91811 OMNIVAN 5ML SYRINGE (B.BRAUN) ( 15-Oct-2024 5.00 90.75
HSN:90183100 ) 17:59.02
(PMIS0215800277 )
38 93498 SENSICARE NITRLE P/F EXAM GLOVES-L 15-Oct-2024 6.00 120.00
100'S (MEDLINE) ( HSN:9019020 ) 12:05.04
(PMIS0215798955 )
39 95368 SODIUM CHLORIDE 500ML STERIPORT 15-Oct-2024 3.00 295.50
(PMIN0215886308 ) 14:34.27
40 99363 STERI-BAND-10CM 15-Oct-2024 1.00 21.00
(PMIN0215886308 ) 14:34.27
41 61787 SUCK CATH 14 ( ROMSONS ) 15-Oct-2024 1.00 77.00
(HSN:90189099 ) 14:34.27
(PMIN0215886308 )

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 6 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146
42 14507 SUPRIDOL 50MG/1ML INJ(HSN:30049069 ) 15-Oct-2024 1.00 13.18
(PMIN0215887196 ) 18:07.44
43 58766SURGICAL BLADE 15(GLASS VAN) 15-Oct-2024 1.00 7.50
(HSN:90189022 ) 18:07.44
(PMIN0215887196 )
44 74913 SURGICARE DUAL GLOVES PF 15-Oct-2024 2.00 330.00
6.5(HSN:90183990 ) 18:07.44
(PMIN0215887196 )
45 73528 SURGICARE DUAL GLOVES PF 15-Oct-2024 2.00 330.00
7#(HSN:90183990 ) 18:07.44
(PMIN0215887196 )
46 85774 SYRINGE 5ML POLYFLUSH 15-Oct-2024 2.00 130.00
(POLYMEDICURE)# ( HSN:90183100 ) 12:05.04
(PMIS0215798955 )
47 40703 SYRINGES 20ML 15-Oct-2024 5.00 150.00
DISPOVAN#(HSN:90183100 ) 14:34.27
(PMIN0215886308 )
48 60628 TEGADERM 1633 (7X8.5CM) FOR CANNULA 15-Oct-2024 1.00 214.00
# ( HSN:30051020 ) 12:05.04
(PMIS0215798955 )
49 27170 TRANEMIC 500MG/5ML INJ ( HSN:30019099 15-Oct-2024 2.00 143.92
) 18:00.55
(PMIS0215800266 )
50 100271 VACCU LINE SUCTION TUBE 2.5M GS-5129 15-Oct-2024 1.00 725.00
S KAD (ROMSONS) 18:07.44
(PMIN0215887196 )
51 17072 VASOCON (ADRENALINE) 15-Oct-2024 3.00 41.07
INJ(HSN:30033900 ) 18:07.44
(PMIN0215887196 )
52 12148 VENFLON PRO SAFETY 20G ( 15-Oct-2024 1.00 485.00
HSN:90183930 ) 12:05.04
(PMIS0215798955 )
16-Oct-2024
1,073.25
1 99706 BAROCID 40MG INJ 16-Oct-2024 2.00 113.00
(PMIS0215804552 ) 17:46.15
2 50420 DYNAPAR AQ INJ 1ML ( HSN:30049066 ) 16-Oct-2024 2.00 79.20
(PMIS0215804552 ) 17:46.15
3 5859 MOXYNIC 1.2GM INJ ( HSN:30041030 ) 16-Oct-2024 2.00 315.02
(PMIS0215804552 ) 17:46.15
4 66346 N.S 100ML (PLASTIC FRESENIUS) ( 16-Oct-2024 4.00 188.36
HSN:25010020 ) 17:46.15
(PMIS0215804552 )
5 91809 OMNIVAN 10ML SYRINGE (B.BRAUN) ( 16-Oct-2024 5.00 143.00
HSN:30049099 ) 17:46.26
(PMIS0215804553 )
6 91811 OMNIVAN 5ML SYRINGE (B.BRAUN) ( 16-Oct-2024 5.00 90.75
HSN:90183100 ) 17:46.26
(PMIS0215804553 )
7 27170 TRANEMIC 500MG/5ML INJ ( HSN:30019099 16-Oct-2024 2.00 143.92
) 17:46.15
(PMIS0215804552 )
17-Oct-2024
99.00

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 7 of 8
Name : Mr. PANKAJ KUMAR SAMADHIYA IP No : IP No : NOIIP107968 Bill No : NOI-ICS-27146
1 69668 DC KIDNEY TRAY WITH HANDLE ( 17-Oct-2024 1.00 99.00
HSN:90189099 ) 8:41.32
(PMIS0215806688 )
(ß) indicates bedside service
(§) indicates stat service Grand Total 161,531.85
(E) indicates dead patient
Rupees One Lakhs Sixty-One Thousand Five Hundred Thirty-Two Only
Bed Details
SI.No From Date To Date Duration Bed No Bed Category
1 15-Oct-2024 10:06 am 15-Oct-2024 5:26 pm 0Days 7Hrs 20Mins MBU-1026 AC-MULTI BED

2 15-Oct-2024 5:26 pm 15-Oct-2024 6:24 pm 0Days 0Hrs 57Mins EM-1022 AC-MULTI BED

3 15-Oct-2024 6:23 pm 17-Oct-2024 11:11 am 1Days 16Hrs 47Mins 1206 AC-MULTI BED

Disclaimer : *All the above dates indicated as Date & Time of the entry only Page 8 of 8
GSTIN : 09AAACI2398N2ZZ OP Cash Bill - Bill of Supply Reference No :

Name : Mr. PANKAJ KUMAR Age : 39Yr 11Mth 24Days UHID: APD2.0000247622

Guardian
SAMADHIYA

: NOT CAPTURED
Sex : Male
*APD2.0000247622*
Name
Address : PAHARI CHUNGI CHIRGAON Jhansi OP Number: NOI1OPP1088277
Uttar Pradesh India284301,
CellNo:91-9821661053 *NOI1OPP1088277*

Pan Number:
Bill No : NOI-OCS-955449
Doctor's Name : Mr. CAPS
Date : 14-Oct-24 Time : 11:44:30
ANAESTHESIOLOGY
Speciality :
*NOI-OCS-955449*
Bill Amount: `. 1,200.00 FOR APOLLO HOSPITALS

Amount in words: ` One Thousand Two Hundred Only

S.No Service Type/Service Name Department Quantity Ref Tariff Dis(%) Amount (INR)

1 Consultation (999311 )
1 OP Consultation - Follow Up Consultation 1 1,200.00 0.00 1,200.00
Visit
Sub Total 1,200.00

Service Amount : 1,200.00

Total Bill Amount 1,200.00

Final Payment (Cash:0.00, NonCash:1,200.00) 1,200.00

No Tax is Payable on Reverse Charge Basis

Receipt Details: Received with thanks sum of `. 1,200.00 (CARD)
` One Thousand Two Hundred Only From Mr. PANKAJ KUMAR SAMADHIYA

*(QR) Denotes Cancelled Services Authorized Signatory

Denotes Quick Registration
Ms. Geeta Kumari Arya

Cashier
Online Payment access- https://pay.apollohospitals.com

Page 1 of 1
 Shop No. 109-B, Antriksh Forest Soc. Sector- 77, Noida, 201304

INVESTIGATION BILL
Lab Code : 131024005 Receipt No : 18,877
Name : Mr. Pankaj Samadhiya Date : 13 Oct 2024,01:13 PM
Age/Sex : 39 Years / Male Center : Dr. Puja s FNAC Clinic & Path Lab
Referral : Contact No : 9821661053

Sr. No. Investigation Charges Discount

1 GLUCOSE RANDOM, Plasma (RBS) 120.00 0.00

2 Complete Blood Count (CBC) 350.00 0.00
3 ESR (ERYTHROCYTE SEDIMENTATION 50.00 0.00
RATE) (ESR)
4 KIDNEY FUNCTION TEST (KFT) 750.00 0.00
5 LIPID PROFILE (LIPID PROFILE ) 750.00 0.00
6 LIVER FUNCTION TEST (LFT) 750.00 0.00
7 PROTHROMBIN TIME (PT) 350.00 0.00
8 Viral Markers 1,700.00 0.00
Total Bill Amount 4,500.00 Net Amount 4,820.00 Paid Amount 4,500.00
Visiting Charges 0.00 Balance Amount 0.00 Discount 320.00
Refund Amount 0
Remark

Payment Mode Cash - 4500.00