Invoice Dentist in Ghana Accra –Free Word Template Download with AI
12 Independence Avenue, East Legon
Accra, Greater Accra Region, Ghana
Tel: +233 30 277 8899 | Mobile: +233 24 555 1234
Email: [email protected]
Website: www.accrapremierdental.com.gh
TIN: GH-1234567890
Invoice Number: APDC-2024-0892
Date Issued: January 15, 2024
Due Date: January 30, 2024
Payment Status: Pending
Reference: Patient File #GH-ACC-4521
Bill To:
Patient Name: Kwame Mensah
Address: 45 Osu Oxford Street, Osu, Accra, Ghana
Phone: +233 20 777 8899
Email: [email protected]
NHIS Number: NHIS-GH-ACC-789456123
Insurance Provider: National Health Insurance Scheme (Ghana)
| # | Description of Dental Services | Date of Service | Quantity | Unit Price (GHS) | Total (GHS) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dental Examination and Consultation - Initial assessment of oral health, review of medical history, and treatment planning at our Accra clinic. | Jan 10, 2024 | 1 | 150.00 | 150.00 |
| 2 | Full Mouth Panoramic X-Ray - Digital radiographic imaging for comprehensive dental evaluation. | Jan 10, 2024 | 1 | 200.00 | 200.00 |
| 3 | Professional Dental Cleaning (Prophylaxis) - Scaling and polishing to remove plaque and tartar buildup. | Jan 10, 2024 | 1 | 350.00 | 350.00 |
| 4 | Composite Filling (Tooth #14) - Restoration of decayed tooth using tooth-colored composite material. | Jan 12, 2024 | 1 | 450.00 | 450.00 |
| 5 | Root Canal Treatment (Tooth #19) - Endodontic therapy including anesthesia, pulp removal, canal cleaning, and temporary filling. | Jan 12, 2024 | 1 | 1,200.00 | 1,200.00 |
| 6 | Dental Crown Preparation (Tooth #19) - Preparation and impression taking for porcelain-fused-to-metal crown. | Jan 12, 2024 | 1 | 800.00 | 800.00 |
| 7 | Temporary Crown Placement (Tooth #19) - Fabrication and placement of provisional restoration. | Jan 12, 2024 | 1 | 250.00 | 250.00 |
| 8 | Local Anesthesia - Lidocaine with epinephrine for pain management during procedures. | Jan 12, 2024 | 2 | 50.00 | 100.00 |
| 9 | Follow-up Consultation - Post-treatment evaluation and adjustment of temporary restoration. | Jan 14, 2024 | 1 | 100.00 | 100.00 |
| 10 | Prescription Medications - Antibiotics (Amoxicillin 500mg) and pain relief medication. | Jan 12, 2024 | 1 | 120.00 | 120.00 |
Amount in words: Two Thousand, Two Hundred and Twenty Ghana Cedis Only
Payment Information
Accepted Payment Methods:
• Mobile Money (MTN MoMo, Vodafone Cash, AirtelTigo Money)
• Bank Transfer (GCB Bank, Ecobank, Stanbic Bank)
• Cash (GHS)
• Credit/Debit Card (Visa, Mastercard)
Bank Details:
Bank: GCB Bank Limited
Branch: East Legon, Accra
Account Name: Accra Premier Dental Clinic Ltd.
Account Number: 0123456789
Sort Code: 012345
Mobile Money: +233 24 555 1234 (MTN MoMo)
Please include Invoice Number APDC-2024-0892 as payment reference.
Important Notes and Terms
1. This invoice is issued by Accra Premier Dental Clinic, a registered dental practice operating in Accra, Ghana, in accordance with the Ghana Dental Council regulations.
2. Payment is due within 15 days from the date of invoice issuance. Late payments may incur a 2% monthly interest charge.
3. National Health Insurance Scheme (NHIS) coverage has been applied where applicable. Please verify your NHIS eligibility and coverage with our billing department.
4. Services not covered by NHIS or additional premium services are billed directly to the patient as indicated above.
5. The final crown placement appointment is scheduled for January 28, 2024. A separate invoice will be issued for the permanent crown fabrication and placement (estimated GHS 1,500.00).
6. Please retain this invoice for your records and for any insurance claims or reimbursement purposes.
7. For questions regarding this invoice, please contact our billing department at [email protected] or call +233 30 277 8899.
8. All dental treatments were performed by licensed dentists registered with the Ghana Dental Council.
9. This document serves as an official receipt upon payment confirmation.
Authorized Signature
Dr. Ama Serwaa Osei
Lead Dentist & Clinic Director
Accra Premier Dental Clinic
Ghana Dental Council Reg. No: GDC-2015-0456
Patient Acknowledgment
Signature: ___________________
Date: ___________________
I acknowledge receipt of this invoice and understand the payment terms.
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