Statement on Payment for Unused Days of the Stay

Sample Patient Statement on Payment of Dues:

I, the undersigned: ………………………………………………………..

Residing at: ………………………………………………………..

Hereby declare that I will pay the amount of ……………….. PLN for the unused days of stay and treatment in the sanatorium (health resort hospital) according to the following calculation:

Number of person-days: ……………….. × price: ……………….. PLN = ……………….. PLN

I undertake to make the payment by ……………….. (date) to the bank account at Alior Bank S.A.
Account number: PL 39 2490 0005 0000 4530 1430 0478

The statement was signed in the presence of:

Note: The template is for informational purposes only