Golden Dermatology
2226 Liliha Street, Suite 302
Honolulu, HI 96817
| ☐ M/C ☐ Visa |
| Card Number |
Exp. Date |
| SignatureX |
CVV # |
| Date |
Pay this amount |
Acct. # |
| 05/04/25 |
$207.82 |
123456 |
| Phone #808-585-8008 |
Page #1 |
Show amount paid here$ |
| Trans ID |
Description |
| 12345678 |
Spring Golden, MD
04/14/25 Office Visit |
150.00 |
|
|
150.00 |
150.00 |
|
| |
|
|
80.00 |
30.00 |
40.00 |
|
40.00 |
| |
|
|
20.00 |
0.00 |
20.00 |
|
40.00 |
