VIO Optical Clinic
Jl. Boulevard Raya Gading Serpong, Ruko 1B Blok BA3 No.29, Kelapa Dua, Tangerang
www.viooptical.com
WA : 082112004933 Ph : 021-5472349
Help You SEE Better
Contact Lens Order Form OR-VGS23000247
Branch
Order Date
: VIO Gading Serpong
: 2023-03-21
*OR-VGS23000247*
*OR-VGS23000247*
SPH CYL AXIS VA SPH CYL AXIS VA
Distance -0.75 -1.50 175 6/6 -0.75 -2.50 175 6/6
Reading Blue HVID 11.0 Grey HVID 11.0
Add Optimum Extreme Add Optimum Extreme
BC (R / L) : Toric Toric Keratometry (R) : 40.85 @ 5 43.16 @ 95
DIA (R / L) : Keratometry (L) : 40.44 @ 178 43.60 @ 88
Date of Delivery : 2023-04-27
Name / ID : Maria Jesselyn Jackqueen / GS001583
Age : 12 Gender : F I/C No. : GS001583
Address : Tangerang,
Home No. : Mobile No. : 081219898899
Office No. : Other No. :
Type Description Amount
R Lens C00273, ORTHO-K SPECIAL DESIGN x 1 7,500,000.00
L Lens C00273, ORTHO-K SPECIAL DESIGN x 1 7,500,000.00
Other 1 A2100000003, ORTHO-K KIT x 1 0.00
Other 2 DISKON OK 500.000, Discount Ortho-k 500.000 x 1 -500,000.00
GST % Amount Tax
Rounding Adjustment Rp0.00
Total Bill Amount Rp14,500,000.00
Storage Location :- Total Amount Due Rp14,500,000.00
Remarks :- BCA Received Rp14,500,000.00
BCA [(VIOREFF147)AE/LI/LV/HR] 14,500,000.00
Issued By : Heru Yoga Pratama Balance Rp0.00
Sales Person : Levi Indriyani
Printed On : 2023-03-21 22:01
- This is a computer generated receipt. No signature is required -
