________ (Name Of The Doctor),
________ (Clinic Name),
Subject: Request for Refund of Fees _______ (Fee Amount)/-
This is in regard to the appointment scheduled at your ________ (Hospital/Clinic) ________ (Address) on ________ (Date) for ________ (Purpose of visit) for Patient ID /Serial No. _________(Patient ID). As per _________(Bill Invoice) issued by ______ (hospital/clinic), the appointment of ________ time on ______ date was given to me.
But due to ______ (explain the problems in detail), I was unable to reach there. As per your _______ (clinic/hospital) policy (if applicable), I would like to request my refund of _________/- (if applicable).
Please do provide me a refund at the earliest.
Waiting for your reply.
________ (Patient ID)
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