Invoice Dentist in Belgium Brussels –Free Word Template Download with AI
123 Avenue Louise
1050 Brussels, Belgium
Phone: +32 2 123 45 67
Email: [email protected]
VAT Number: BE0123.456.789
INVOICEInvoice Number: INV-2024-0892
Date of Issue: October 15, 2024
Due Date: November 15, 2024
Payment Terms: Net 30 Days
Patient Name: John Doe
Address: 45 Rue de la Loi
City: 1040 Brussels, Belgium
National Register Number: 850101 123 45
Insurance Provider: Mutualité Chrétienne
Policy Number: MC-987654321
Treating Dentist: Dr. Marie Dupont
Specialization: General Dentistry & Orthodontics
License Number: 123456
Clinic Location: Brussels, Belgium
Appointment Date: October 10, 2024
Appointment Time: 14:30 - 15:45
This invoice details the dental services provided by our qualified dentist in Brussels, Belgium, in accordance with the official Belgian dental tariff guidelines. All procedures were performed at our Brussels clinic with the highest standards of care and professionalism.
| Item # | Description of Dental Service | Code | Quantity | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|---|
| 1 | Comprehensive dental examination and consultation by dentist | 01.01 | 1 | 45.00 | 45.00 |
| 2 | Full mouth radiographic examination (panoramic X-ray) | 02.05 | 1 | 65.00 | 65.00 |
| 3 | Professional dental cleaning and scaling (supragingival) | 03.02 | 1 | 85.00 | 85.00 |
| 4 | Composite filling (tooth #14, Class II restoration) | 04.12 | 1 | 120.00 | 120.00 |
| 5 | Composite filling (tooth #26, Class I restoration) | 04.11 | 1 | 95.00 | 95.00 |
| 6 | Fluoride treatment for cavity prevention | 05.03 | 1 | 25.00 | 25.00 |
| 7 | Oral hygiene instruction and personalized dental care plan | 06.01 | 1 | 30.00 | 30.00 |
| 8 | Follow-up consultation with dentist (post-treatment review) | 01.02 | 1 | 35.00 | 35.00 |
Subtotal: €500.00
VAT (21%): €105.00
Insurance Reimbursement (Estimated): -€180.00
Total Amount Due: €425.00
Note: The insurance reimbursement amount is an estimate based on standard Belgian mutual insurance coverage. Actual reimbursement may vary depending on your specific policy with your mutualité. Please submit this invoice to your insurance provider for processing.
Please remit payment within 30 days of the invoice date. Payment can be made via bank transfer to the following account:
Bank: KBC Bank
Account Holder: Brussels Dental Care Center
IBAN: BE68 5390 0754 7034
BIC: KREDBEBB
Reference: INV-2024-0892
For any questions regarding this invoice or your dental treatment in Brussels, Belgium, please contact our office directly.
Important Notes
- This invoice is issued in accordance with Belgian tax regulations and dental practice standards.
- All dental services were performed by a licensed dentist registered in Belgium.
- Please retain this invoice for your records and for submission to your mutual insurance company.
- Payment is due within 30 days. Late payments may incur a statutory interest charge as per Belgian law.
- If you have any disputes regarding the charges, please contact us within 14 days of receiving this invoice.
- Our Brussels clinic is committed to providing high-quality dental care in a comfortable and professional environment.
Authorized by:
Dr. Marie DupontDentist
Brussels Dental Care Center
Patient Acknowledgment:
Signature: _________________________Date: _________________________
Brussels Dental Care Center | 123 Avenue Louise, 1050 Brussels, Belgium | VAT: BE0123.456.789
This invoice is a valid legal document for dental services rendered in Brussels, Belgium.
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