Kapolei Eye Care
511 Manawai St. Unit 401
Kapolei, HI 96707
| ☐ M/C ☐ Visa |
| Card Number |
Exp. Date |
| SignatureX |
CVV # |
| Date |
Pay this amount |
Acct. # |
| 11/20/24 |
$207.82 |
123456 |
| Phone #808-674-2273 |
Page #1 |
Show amount paid here$ |
| Trans ID |
Description |
| 12345678 |
Chen, Nancy MD
10/31/24 Office Visit |
150.00 |
|
|
150.00 |
150.00 |
|
| |
|
|
80.00 |
30.00 |
40.00 |
|
40.00 |
| |
|
|
20.00 |
0.00 |
20.00 |
|
40.00 |
