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Payment Receipt Form

Balance Summary

Total Amount: 0.00 EUR

Total Received Amount: 0.00 EUR

Balance: 0.00 EUR

Booking Notes

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Patient

Payment Type

Payment Method

Payment Date

Amount to be Collected from Patient

* Adds 20% (VAT) + 2.05% (Bank Comm.) to Sent Amount.

Sent Amount to Account

Received Amount to Account

Net amount after financial institutes (Banks, WU, Moneygram, Wise etc.) deductions

Quote Currency Equivalent

Since the currency does not match the Deal Currency, please enter the equivalent amount of this payment in Deal Currency (the quote currency). The balance will be calculated based on this amount.

Payment Holder Position

Payment Holder Name

Payment Notes

Payment Document/s

Product Management

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