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Free Furlong Vision Correction Receipt Generator

Eye care service receipt from Furlong Vision Correction Eye Center detailing patient information, eye examination and diagnostic services, individual service charges, subtotal, tax, total amount paid, payment method, transaction date and time, and provider/license details.

Furlong Vision Correction Eye Center
 
Address:
2107 N First St #101
Phone Number:
(866) 702-5776
Website:
furlongvision.com
:::::::::::::::::::::::::::::::::::::
=====================================
Doctor:
Dr. Furlong
License Number: DDS-482736
=====================================
Patient:
Name: Mark
Surname: Bishop
Number: (415) 791-2107
Insurance Number: N/A
Email: mark715bishop@proton.me
=====================================
Comprehensive Eye
$525.00
Examination (Level V)
Optical Coherence
$750.00
Tomography (OCT)=
Visual Field Testing
$575.00
Retinal Imaging
$485.00
Medical Interpretation
$425.00
& Clinical Analysis
Administrative Fee
$215
Subtotal
$2975.00
Tax
$245.48
Total
$3220.48
=====================================
Card number
**** **** **** 8786
Card type
Debit
Card entry
Chip
Date/time
5/24/2025 9:02 AM
Reference #
62845289260246240685C
Status
APPROVED
=====================================
Many hospitals and dental offices offer
electronic receipts via email or patient
portals for convenience and record-keeping.
They must have clear procedures for
patients to dispute charges and request
corrected receipts if errors are found.
Receipts should clearly list services
rendered (e.g., consultation, lab tests,
imaging), medications, procedures, and any
other charges.
5/24/2025, 9:02:48 AM

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