15
MAY
Annual Checkup
Monday, May 15, 2023 ยท 10:30 AM
Clinic Information
City Care Clinic
123 Healthcare Street
Suite 200
0.8 miles away
Healthcare Provider
Dr. Sarah Miller
General Physician
4.9
|
10+ years exp.
Patient Information
Full Name
John Doe
Date of Birth
January 15, 1990
john.doe@example.com
Phone
(555) 123-4567
Payment Method
Other Payment Options
Payment Summary
Consultation Fee
$120.00
Booking Fee
$10.00
Insurance Coverage
- $80.00
Total Amount
$50.00
Insurance Applied
Your insurance coverage has been verified and applied to this payment.