Invoice Dentist in Chile Santiago –Free Word Template Download with AI
Av. Providencia 1234, Oficina 501
Providencia, Santiago, Chile
RUT: 76.543.210-K
Phone: +56 2 2345 6789
Email: [email protected]
Invoice Number: INV-2023-0892
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Payment Terms: Net 14 Days
Notice: This invoice is issued in accordance with the regulations of the Servicio de Impuestos Internos (SII) of Chile. All prices are quoted in Chilean Pesos (CLP). This document serves as a formal request for payment for dental services rendered in Santiago. Bill To:Mr. Roberto Fernandez
RUT: 15.987.654-3
Las Condes, Santiago, Chile
Email: [email protected]
Patient Information:Patient Name: Roberto Fernandez
Insurance Provider: Isapre Cruz Blanca
Policy Number: CB-99887766
Treatment Plan ID: TP-2023-445
| # | Description of Dental Services | Code (CDS) | Quantity | Unit Price (CLP) | Total (CLP) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Initial Consultation Includes panoramic X-ray analysis, periodontal screening, and oral cancer screening performed at our Santiago clinic. |
01010 | 1 | $45.000 | $45.000 |
| 2 |
Professional Dental Prophylaxis Deep cleaning procedure including scaling and polishing to remove tartar and plaque buildup. |
01110 | 1 | $85.000 | $85.000 |
| 3 |
Composite Resin Restoration (Anterior) Tooth #11. Aesthetic filling using high-grade composite material matched to natural tooth shade. |
02220 | 1 | $120.000 | $120.000 |
| 4 |
Root Canal Therapy (Single Canal) Tooth #36. Endodontic treatment including access, cleaning, shaping, and obturation. |
03310 | 1 | $250.000 | $250.000 |
| 5 |
Porcelain Crown Preparation Tooth #36. Preparation of tooth structure and placement of temporary crown. |
04410 | 1 | $180.000 | $180.000 |
| 6 |
Local Anesthesia Administration of lidocaine with epinephrine for pain management during procedures. |
05510 | 2 | $15.000 | $30.000 |
| 7 |
Follow-up Examination Post-operative check to ensure healing progress and comfort. |
01020 | 1 | $35.000 | $35.000 |
Please make payment via bank transfer to the following account in Chile:
- Bank: Banco de Chile
- Account Type: Current Account (Cuenta Corriente)
- Account Number: 1234567890123
- CLABE: 715012345678901234
- Reference: INV-2023-0892
1. This invoice is valid for 30 days from the date of issue. Late payments may incur a penalty fee of 2% per month.
2. All dental services were performed by licensed professionals registered with the Colegio de Dentistas de Chile.
3. The IVA (Impuesto al Valor Agregado) of 19% is mandatory according to Chilean tax law.
4. Insurance coverage amounts are estimates based on pre-authorization. The patient is responsible for any discrepancies.
5. Please retain this invoice for your personal records and tax purposes.
Santiago Dental Excellence is committed to providing high-quality dental care in Santiago, Chile. We adhere to all local health regulations and privacy laws. This document is generated electronically and is legally binding. For any questions regarding this invoice, please contact our billing department during business hours (Monday to Friday, 9:00 AM to 6:00 PM). Thank you for choosing our dental services.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT