Page 26 - Chatham-Kent Hospice
P. 26

derstand
* SAM
rmacy In
Over the counter
NOT PAY
l Health Solutions Pha ess
Province, Postal Code 888) 888-8888
3
Resident Name Address
City, Province, Po
xxxxx 1 Pre Last
.
name, First name) Last
Last name, First name
Unde
 rstanding Your Pharmacy Invoice Understanding Your Pharmacy Invoice
                                   * SAMPLE ONLY – DO NOT PAY *
* SAMPLE ONLY – DO NOT PAY *
Understanding Your Pharmacy Inv
oice
Rexall Health Solutions Pharmacy
Address
City, Province, Postal Code
Tel: (888) 888-8888
Rexall Health Solutions Pharmacy Address
City, Province, Postal Code
Rexall Health Solutions Pharmacy Tel: (888) 888-8888
xxxxx
xx
Resident Name
Address
Resident Name
City, Province, Postal Code
Address
* SAMPLE ONLY – DO NOT PAY *
 Address
City, Province, Postal Code Tel: (888) 888-8888
City, Province, Postal Code Resident Name
Address
City, Province, Postal(LCaosdtename, First name)
(Last name, First name)
2
Charge
   1
Previous Balance
2
Charge 59.97
 1 Previous Balance
1 Previous Balance
(Last name, First name)
59.97
Last name, First name
2 Char 5
Last name, First name
Last name, First name Last name, First name Last name, First name
 ing Your Pharmacy Invoice
PLE ONLY – DO NOT PAY * Last name, First name Last name, First name
voice
r* macy
3otalDue
3 Total Due
stal Code
vious Balance name, First name
2
name, First name
Last name, First name
Last name, First name
Lastname,FirLsatsntanmamee,Firstname
Last name, First name
  3T Total Due
Resident Name
Address
City, Province, Postal Code
xxxxx
ChaTregel: (888) 888-8888 59.97
Address
Resident Name
xxxxx
xxxxx
Address
City, Province, Postal Code
xxxxx Resident Name Address
City, Province, Postal Code
(Last name, First name)
Rexall Health Solutions Pharmacy
Rexall Health Solutions Pharmacy
1
2
Amount owing from last invoice
Charge: amount resident pays. Over the counter products and items not covered by ODB are charged weekly.
Address Address
City, Province, Postal Code
City, Province, Postal Code
Rexall Health Solutions Pharmacy Tel: (888) 888-8888
City, Province, Postal Code
Tel: (888) 888-8888
2
Charge 59.97
1 Amount owing from last invoice.
xxxxx
xxx
xxxxx
Amount owing fr
ge1
1
2
Total amoTuonttaloaw 33
1 Amount 9.97
Charge: amount r
2 Over th items not covere
charged weekly.
Charge:
items n
charged
2
 Charge: amount resident pays. Over the counter products and items not covered by ODB are charged weekly.
  2
  Las1t na
Amount owing from last invoice.
 me, First name
  3
Total amount owing.
                                                                                                                                                                                                                                                                          n
a
Ol
e
e
Charge: amount resident pays.
o
d
o
m
AMPLE SAMPLE
SAMPLE
SAMPLE SAMPLE
   24   25   26   27   28