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THERAPY RECEIPT
Outpatient Clinic:
Riverside Health Clinic
Phone: (415) 555-0139
Patient: Olivia Nguyen
Provider: Dr. S. Patel
Service: Specialist Consultation
02/14/2026, 21:06:49
Provider:
ClearMind Therapy Center
Licensed Clinical Psychologist
Patient:
Emily Carter
Session Date: 04/02/2032
Session Length: 50 minutes
Individual Therapy Session
$165.00
Total Paid
$165.00
Card number
**** **** **** 1234
Card type
Debit
Card entry
Chip
Date/time
06/04/2022 9:35 AM
Reference #
11111111111111A
Status
APPROVED
Therapy Receipt
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