Invoice Dentist in Brazil Brasília –Free Word Template Download with AI
Brasília Dental Care Center
Professional Dental Services
Invoice Number: INV-2024-0892
Date: October 15, 2024
Due Date: November 15, 2024
Status: Pending Payment
Company Name: Brasília Dental Care Center Ltda. CNPJ: 12.345.678/0001-90 Address: SHIS QI 15 Conjunto 22 Casa 10Lago Sul, Brasília - DF
CEP: 71625-300 Lead Dentist: Dr. Carlos Eduardo Silva CRD-DF: 12345 Contact: Phone: (61) 3245-6789
Email: [email protected] Full Name: Maria Fernanda Oliveira Santos CPF: 123.456.789-00 Address: SQS 310 Bloco A Apartamento 45
Asa Sul, Brasília - DF
CEP: 70365-020 Phone: (61) 98765-4321 Email: [email protected] Insurance: Unimed Brasília
Policy Number: 987654321
This invoice details the professional dental services provided at our Brasília clinic. All procedures were performed in accordance with Brazilian dental standards and regulations established by the Conselho Federal de Odontologia (CFO).
| Item | Description | Code | Date | Quantity | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|---|
| 1 | Comprehensive Dental Examination and Consultation | 93103 | Oct 10, 2024 | 1 | R$ 250,00 | R$ 250,00 |
| 2 | Full Mouth Panoramic X-Ray | 70150 | Oct 10, 2024 | 1 | R$ 180,00 | R$ 180,00 |
| 3 | Professional Dental Cleaning (Prophylaxis) | 93460 | Oct 12, 2024 | 1 | R$ 320,00 | R$ 320,00 |
| 4 | Composite Filling - Upper Right Molar | 2750 | Oct 14, 2024 | 1 | R$ 450,00 | R$ 450,00 |
| 5 | Root Canal Treatment - Lower Left Premolar | 3040 | Oct 15, 2024 | 1 | R$ 1.200,00 | R$ 1.200,00 |
| 6 | Dental Crown Preparation and Temporary Crown | 2740 | Oct 15, 2024 | 1 | R$ 850,00 | R$ 850,00 |
| 7 | Follow-up Consultation and Treatment Planning | 93103 | Oct 15, 2024 | 1 | R$ 200,00 | R$ 200,00 |
Subtotal: R$ 3.450,00
Insurance Coverage (Unimed Brasília): -R$ 1.200,00
Discount Applied: -R$ 150,00
ICMS (Tax): R$ 270,00
Total Amount Due: R$ 2.370,00
Payment is due within 30 days from the invoice date. Please use one of the following payment methods:
- Bank Transfer: Banco do Brasil, Agency: 1234-5, Account: 67890-1, PIX Key: [email protected]
- Credit Card: Available in installments up to 6x without interest
- Boleto Bancário: Available upon request
Please reference the invoice number (INV-2024-0892) when making your payment.
This invoice represents professional dental services rendered in Brasília, Brazil, in compliance with all applicable Brazilian healthcare regulations. Brasília Dental Care Center is committed to providing high-quality dental care using modern techniques and materials approved by the Brazilian Health Regulatory Agency (ANVISA).
All procedures were performed by licensed dentists registered with the Regional Dental Council of the Federal District (CRD-DF). If you have any questions regarding this invoice or the services provided, please contact our office during business hours (Monday to Friday, 8:00 AM to 6:00 PM).
For insurance claims, please submit this invoice along with the detailed treatment report to your insurance provider. Our administrative team is available to assist with any documentation required by Brazilian health insurance companies.
Thank you for choosing Brasília Dental Care Center for your oral health needs. We appreciate your trust in our professional services and look forward to continuing to serve you.
Authorized by:
Dr. Carlos Eduardo SilvaLead Dentist
CRD-DF: 12345
Received by:
Client SignatureDate: _______________ ⬇️ Download as DOCX Edit online as DOCX
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