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Promissory Note Promissory Note: Mauban District Hospital Mauban District Hospital

The document contains a promissory note template from Mauban District Hospital. The template includes fields for the patient's name, address, contact number, total bill amount, any partial payment made, remaining balance, and due date. It also includes signature lines for the payer to sign with their printed name and relation to the patient.

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KC Palattao
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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666 views2 pages

Promissory Note Promissory Note: Mauban District Hospital Mauban District Hospital

The document contains a promissory note template from Mauban District Hospital. The template includes fields for the patient's name, address, contact number, total bill amount, any partial payment made, remaining balance, and due date. It also includes signature lines for the payer to sign with their printed name and relation to the patient.

Uploaded by

KC Palattao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MAUBAN DISTRICT HOSPITAL MAUBAN DISTRICT HOSPITAL

Mauban, Quezon Mauban, Quezon

PROMISSORY NOTE PROMISSORY NOTE

Date: ________________ Date: ________________

Patient’s Name: ______________________________ Patient’s Name: ______________________________


Address: ___________________________________ Address: ___________________________________
Contact No.: ________________________________ Contact No.: ________________________________
Total Bill: ___________________________________ Total Bill: ___________________________________
Partial Payment: _____________________________ Partial Payment: _____________________________
Balance: ____________________________________ Balance: ____________________________________
Due Date: __________________________________ Due Date: __________________________________

_________________________________ _________________________________
Payer’s Signature Under Printed Name Payer’s Signature Under Printed Name
Relation to the patient: ____________ Relation to the patient: ____________

MAUBAN DISTRICT HOSPITAL MAUBAN DISTRICT HOSPITAL


Mauban, Quezon Mauban, Quezon

PROMISSORY NOTE PROMISSORY NOTE

Date: ________________ Date: ________________

Patient’s Name: ______________________________ Patient’s Name: ______________________________


Address: ___________________________________ Address: ___________________________________
Contact No.: ________________________________ Contact No.: ________________________________
Total Bill: ___________________________________ Total Bill: ___________________________________
Partial Payment: _____________________________ Partial Payment: _____________________________
Balance: ____________________________________ Balance: ____________________________________
Due Date: __________________________________ Due Date: __________________________________

_________________________________ _________________________________
Payer’s Signature Under Printed Name Payer’s Signature Under Printed Name
Relation to the patient: ____________ Relation to the patient: ____________

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