Company Name: _______________
HOSPITAL
BILL
Name: _______________
Street Address: _______________
City, State: _______________
ZIP Code: _______________
Phone: _______________ INVOICE
E-mail: _______________
Invoice # _______________ Date: _______________
Client / Customer
Name: _______________
Street Address: _______________
City, State: _______________
ZIP Code: _______________
Description Amount ($)
Comments or Special Instructions: SUBTOTAL
___________________________________________ DISCOUNT
Payment is due within ____ days. TAX
TOTAL
Thank you for your business!