20466 Prescription

(This prescription is valid at any insurance pharmacy.)

Beneficiary Insurer
No. Number
Insurance --
Waived /

Patient Name Skhama Address Details :

Yasuaki of Taito-ku,
Khemka Tokyo office / 1, Name three 1-7-3
Birth date 1969.June.1 Female
Maison - de Sato 4 F
5
Classification Self Responsibility
ratio
Date of issue 25 May 2016 Yuri 03-3851-3085
1 3 1 0 6 2 7 7 3 7

Rp1
Lokisonin Tablet 60 mg 3
Mukosuta Tablet 100 mg 3
3 times a dayMorning, Noon and Evening after X 7 Days
meals

Remarks In the case of drugs, Please use patient Address

Remark Drug Manufacturers license number Insurance Doctor
Signature

Dispensing pre-
date
Patient number : 20466 : SCHEDULE / CALENDER OF VISITS
Patient name: Skhama Khemka

Please bring paper during next medical check up. For in case of any other symptoms please
have a word at reception.

Next Appointment Next medical check up contents Sign

On date 5/28 CD-ROM distribution, medical check
up, X-Ray, prescription, injection,
measures for disease
On date Medical examination, X-Ray,
Prescription, Injection, Measures for
disease
On date Medical examination, X-Ray,
Prescription, Injection, Measures for
disease

Sato Orthopaedics
Document for Medical Treatment Details

Patient Number 20466 Syama Kemuka Clinic (OPD)

Visit Date : 28-5-25

Classification Number Frequency Amount

First. Re-visit Re-check 72
Line system detail addition 1

Clinic management addition 52 1

Dosage Prescription amount (others) 68 1

Total 193 0
Re-issue of the medical specification will not be done. Date of issue: 28/5/2016
Medical Corporation Association Sato orthopedic
Tokyo-bu, Taito-ku,
Misuji 1-7-3 Maison - de

Sato 4 F

Tel : 03-3851-3085

The medical fees and drug prices include consumption tax set by the Health, Labour and Welfare
section.
Patient Number 20466 Name SyamuKemuka
28-5-24

Claffication
First-Re- First medical check up 282 1
visit

Proof of Prescription amount 2 70 1

medication
Measures Broken Rib operation 500 1
Image Image Check up
Check up
Digital Image Electronic image maintenance
Digital Image frequency thrice and left rib 363 1
1215 0
28-5-24
Patient Number SyamuKemuka
20466 28-5-24

Medical Domestic. Receipt No Issued Bearer Self or Classification

Examination Foregin Date Family
section
Orthopedicsdept Foreign 44 28-5-24 100 % Self Self

Isuranc First.R Medical Home Inspectio Image Proof of Injectio Rehabilitati

e e- Manageme Medical n checku medicati n on
check nt care p on
282 363 70
X Disposal Operatio X X Patholog Others
n y check
up
500

IsuranceO Medic Correspon Mater (1) (2) (3)Expe (4)Expe (5)Expe (6)Expe
utside al dence ial Expen Expen nses nses nses nses
Bearer check section expen ses ses
up ses
docu
ment

Total Bearer Expenses tax Outstanding

amount Amount
Insurance 12150 12150 Adjusted
Amount
Insurance Receipt total 12150
Bearer
111-0055

1-7-3

Tel : 03-3851-3085 Fax

 28-5-24

28-5-24

Classification Prescription details Frequency Points/Total

Pharmacy check up 1 41
Base pharmacy additions 1 32
Pharmaceutical section Inner medication 21
External use medicines 10
Pharmaceuticalsmedicines operations totals 104
Medical Operation + pharmaceuticals 1 50
management
50
Calories 300 mg 10 8
LokinPulofin100 mg Kog : 10 X 14 cm 1 48
21
Medicine totals 56
Totals 210

2-8-9 YS 1F

Tel- 03-3851-3636
Patient Number Name
SyamuKemuka

Receipt No Issued Date Pharmacy Expenses Bearer Self.family

date classification discount
28-5-24 28-5-24 10 Others

Insurance Pharmacy Medicine Drug section Specific insurance

operations management medicare
section
104 50 56 0

Insurance outside Evaluation Others Insurance Insurance outside

bearer medicare bearer
0 Total 2100 0
Bearer 2100 0
Receipt 2100
Total

2-8-9-1 0 1

Tel : 03-3861-3636 FAX 03-3861-3638

Patient No Name Medication date
20466 SyamuKemuka 28-05-25

Medical Domestic. Receipt No Issued Bearer Self or Classification

Examination Foregin Date Family
section
Orthopedicsdept Foreign 47 28-05-25 100 % Self Self

Insuran First.R Medical Home Inspecti Image Proof of Injectio Rehabilitati

ce e- Manageme Medical on checku medicati n on
check nt care p on
125 68
X Disposal Operatio X X Patholog Others
n y check
up

Insuran Medical Corresponde Materi (1) (2) (3) (4) (5) (6)
ce check nce section al Expens Expens Expens Expens Expens Expens
Outsid up expens es es es es es es
e docum es
Bearer ent

Total Bearer Expenses Tax Outstanding

Amount
Insurance 1930 1930 Adjusted
amount
Outside Receipt total 1930
Insurance
bearer

111-0055

1-7-3

Tel : 03-3851-3085 Fax :

Patient Number 20466 Name SyamuKemuka
: 28-5-28

Classification
First. Re-check up Re-check up 72
System details 1
issued date
addition
Outside 52 1
medication
management
X-P (CD) 1 3000

Totals 125 3000

28-5-28

1-7-3

Tel : 03-3851-3085
Patient Number Name Receipt Date
20466 Syamukemuka 28-05-28

Medical Domestic. Receipt No Issued Bearer Self or Classification

Examination Foregin Date Family
section
Orthopedicsdept Foreign 53 28-5-28 100 % Self Self

Insuran First.R Medical Home Inspecti Image Proof of Injectio Rehabilitati

ce e- Manageme Medical on checku medicati n on
check nt care p on
125
X Disposal Operatio X X Patholog Others
n y check
up

Outsid Medical Corresponde Materi (1) (2) (3) (4) (5) (6)
e check nce section al Expens Expens Expens Expens Expens Expens
Insuran up expens es es es es es es
ce docum es
Bearer ent
3000

Total Bearer Expenses tax Outstanding

amount
Insurance 1250 1250 Adjusted
Amount
Outside 3000 3000 Receipt total 4250
Insurance
Bearer

111-0055

1-7-3

Tel : 03-3851-3085 Fax

 Todays Medicine 28-05-24 Page :

SyamuKemuka (16176-1)

Dr.

(Tel : 03-3861-3636 Fax : 03-3861-3638)

Calories 300
1 x 10 1
It has efficiency of reducing fever, and
pains

Acetoamisofin
: 8.5 1 1
Lokinpurofin Na tape
00mg 1k : 21
This has the efficiency of supressing
inflammation and softening pains
Till date if anyone has eaten Asupurin
other medicines then please notify
this to your doctor

090-8035-1775
 No. 20466

28 1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12

Please bring this medical prescription during your next medical check up.

Also please present Insurance proof when you visit for the first time check up of a month

If there are address or name changes in the insurance proof, then please mention them
without fail

This is a permanent/original receipt. Please maintain it carefully (do not loose it)

9.00-
12.30
15.00
18.30

1-7-3

Tel : 03-3851-3085
28 1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12

Please bring this medical prescription during your next medical check up.

Also please present Insurance proof when you visit for the first time check up of a month

If there are address or name changes in the insurance proof, then please mention them
without fail

This is a permanent/original receipt. Please maintain it carefully (do not loose it)

9.00-
12.30
15.00
18.30

1-7-3

Tel : 03-3851-3085