[outlet]-[Billtype]
Patient ID [Patient Id] Refund # [RefundNo]
Patient Name [PatientName] Refund Date [RefundDate]
Address [Address]
[contactno]		 Package [Package]
Bill # [Bill No] Doctor Dr. [doctor]
Bill Date [Bill Date] Mobile No [contactno]
[Customer] [CustomerName]
[InsuranceDetails]
[item List]
[Remarks]
Gross Amount [gross]
Discount [discount]
Net Amount [NetAmnt]
[TaxHead] [Tax]
[CgstHead] [CgstMast]
[SgstHead] [SgstMast]
[PaidAmount] [payamt]
Total Amount [TotalAmount]
Non insured Amount [NonInsuredAmount]
Co-Pay/Deduct Amount [CopDeduct]
Refundable Amount [refund]
Claimed Amount [ClaimedAmount]
Patient Refundable : [PtPayableInWords]
Claimed Amount : [ClaimedAmountInWords]

Outlet : [outlet],[counter]

Signature & Stamp

[User]

Cashier