Form 104-W - Ledger and Treatment Record

Ledger and Treatment Record
Space for all the information necessary to render the patient’s statement, including charges, payments, balance, caregiver’s name and initials
Fits 101 style envelopes and other folders
Back is the same as front except without patient address, etc.
Size 8.5” x 11"
Printed 2 sides
Black ink on white index stock
100 Per Package.