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VAT. No: 456******* TAX INVOICE Invoice Date: **/*6/16

* CREDIT NOTE/STATEMENT Practice No. : 052********** Registration No.: 2007/018337/21

Private Bag X9, Highveld Park 0067 Tel: 012-***-**** Fax: 012-*******/1/2 166 Witch-Hazel Ave, Technopark, Highveld Park

Invoice No.: IKG59539 ID-Number: 870**********

Guarantor Information Patient Information Medical Aid Information VAT. No : Patient : Theko,Grett Private Patient

Grett Theko Birthdate : 07/08/87 Member Number:

58 Paul Mills Street Dependant :

Musina Schmidt,R Auth Number :

0900 Pract. No. : 013**********

Ref. Diagnostic Code: Z76.9

Serv. Date Lab. No. Code Description ICD Qty Total

08/06/16-166*****-**** Histology Block per Sample L43.9 1 327.60 Total Debits, Credits (14% VAT Included) 327.60

Less Payments 0.00

Amount Outstanding 327.60

This invoice covers pathology tests requested by your doctor to whom your test results have been sent. Payment is strictly 30 days from date of invoice. Note: If you belong to a medical aid, kindly contact us, and furnish us with the details, to avoid any inconvenience.

* This serves as a Credit Note for Credit Transactions (Test Cancelled).

REMITTANCE ADVICE Bank Details

A Fee of R75.00 will be levied on unpaid cheques

Cheques Payable To: Drs Du Buisson, Kramer Swart, Bouwer Inc./Ing. Standard Bank, Centurion, 012645 Acct. No: 410371475

Inv No : IKG59539 Bank Ref. No : IKG59539

Patient : Theko,Grett Amount Outstanding : 327.60

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