.
STATEMENT OF SERVICES RENDERED "
CHART NO. PAGE NO.
Kartheek Dobbala, DDS
121 , 4820 Northland Dr NW
Calgary, AB T2L-2L4
I DE0246 I 1 I
(403)284-3341
I Blt LIHG DATE I
01/10/2024
GUARANTOR NAME AND MAILING ADDRESS
Sapna Deb
3524 31st Street NW
Calgary, AB T2L-2A5
-
PATIENT TOOTH SURF DESCRIPTION CHARGE CREDIT
Sapna Exam, Emergency 87.33
Sapna 1 PA 41 .33
Sapna Debit -1 28.66
PRIOR BALANCE CURRENT CREDITS I CURRENT CHARGES I NEW BALANCE I DENTAL INS. EST.
I PLEASE PAY
I I I I I
0.00 128.66 + 128.66 0.00 0.00 0.00
I I i i i
PATIENT DATE TIME REASON
Sapna Monday - 7 October 2024 11:30 am Ext, surg#17
Thank you for your payment
\. ,
Copyright© 1987-2022 Henry Schein, lnall.WLK 1
BRENT~OOD DENTAL CENTR
121 - 4820 NORTHLA T2L2L4
CALGARY AB
TM2408612403
DEBIT SALE
Batch #: 360 RRN: 0013600030
10/01/24 11:35:24
Invoice #: 3 REF#: 00000003
APPR CODE: 003815
IDP/DEFAULT Proximity
************8340
lnterac
AID: A00000027710100100000001
AMOUNT $128.66
001 APPROVED
CUSTOMER COPY
3 FD 2 72 2 3 17 7 D :SP WC n n
Kartheek Dobbala, DDS
Name Sapna Deb
.: TREATMENT CASE Treatment Plan
VISIT TOOTH SURF CODE PROV DESCRIPTION FEE PATIENT
1 17 71201 KOOC Surgical extraction 339.62 339.62
Visit 1 Totals: 339.62 339.62
I Primary
:: INSURANCE PROVIDER(S) ::
Secondary Fee
339.62 339.62
:: TOTALS ::
IPatient I I ia
0"
,,. 17 11 15 •141 131 12 11 ,21, ,221 23 <24 •25, 12111 27 21 ::::::s
;d >~r'. \ \~ -l i 11l~l~~ Treatment Plan Total
:: FINANCIAL SUMMARY ::
E1tlmated Deductible to be Applied
339.62
0.00
I
0
I , ., ) J.D., Estimated Insurance Payment
E1tlmated Patienra Portion
0.00
339.62
C.
C.
t I ! J i .,\ .J Patient Balance 128.66 Cl)
! ,~~~~
Fee Expiration Date 01 /01/2025
,.
::::::s
; rlN v ~ 1J if
,48, 47 46 45
, 1 ~if ~TI i
441 43 42 , 1 131 I 321 33 1 (34 •351 ,36, 37, JS
m
n
Cl)
,.
::::::s
.;n
Alternate C . -:
Case notea:
The estimate provided is valid for 3 months from date signed.
This is an estimte only and may changeifclinlcally indicate. We will make every effort to inform the patient of any 0
unexpected changes to fees or to treatment. 3
X)
IEI
~ CA~WiifB'i~arm acy #4 Brentwood ~ atdffi
~p,armacy #4 Brentwood
~ p~~ Rd. NW Tel: (403) 299-4308 ~ PHAAMACJl'wood Rd. NW Tel: (403) 299-4308
Celger,, AB T2L l:IEB Te,ct,(587) 871 BJJJ Calgary, A8 TU 1K8 Texl,(587) 871•8!!!
OFFICIAL PRESCRIPTI ON RECEIPT
Patient Counselling Messages
Rx: 3587321 MZ ~ SIV-Amoxicillin DIN: 02401509
Deb, Sapna Tue 01-0ct-2024 C:l •
3524 - 31 Street Nw . Do not take if you are allergic to penicillin
Calgary AB T2L 2A5 (825) 962-8192 - Tell doctor what medicines you are taking
21 CAP SIV-Amoxicillin 500mg Must use for full length of treatment
Amoxicillin Trihydrate 500mg NEW RX Space doses evenly throughout the day
DIN: 02401509 Mfr: SIV Days: 7 Refills: 0 Call DR if rash or severe diarrhea occur.
Dr. Dobbala, Kartheek Doc# 85:88111 OT Watch for oral thrush or vaginal yeast infections.
Total: 15.18 Third Part Tell doctor your complete medical history
0.00
Patient Pays: 15.18 0
Sign up for text refills.
Register your cell number with us today.
TEXT YOUR REFILLS to 587-871-8333
Kartheek Dobbala, DDS
121, 4820 Northland Dr NW
Calgary, AB T2L-2L4
(403)284-3341
Sapna Deb
3524 31st Street NW
Calgary, AB T2L-2A5
Surgical extraction 339.62
Debit -339.62
Thank you for your payment
Copyright© 1987-2022 Henry Schein, lncni.wLK 1
BRENTIIVOOD DENTAL CENTR
121 - 4820 NORTHLA T2L2L4
CALGARY AB
24086124
TM2408612402
DEBIT SALE
Batch #: 571 RRN: 0015710090
10/07/24 12:13:35
Invoice #: 8 REF#: 00000009
APPR CODE: 007578
DP/CHEQ~G Chip
............***4241
NTERAC
All: A0000002771010
AMOUNT $339.62
001 APPROVED
CUSTOMER COPY
