Invoice Dentist in Indonesia Jakarta –Free Word Template Download with AI
Address: Jl. Sudirman No. 45, Menteng, Central Jakarta
City: Jakarta, Indonesia
Phone: +62 21 555 0199
Email: [email protected]
NPWP: 01.234.567.8-901.000
Date: October 24, 2023
Due Date: November 07, 2023
Bill To:
Patient Name: Budi Santoso
Address: Jl. Gatot Subroto Kav. 10, Kuningan
City: South Jakarta, Indonesia
Phone: +62 812 3456 7890
Patient ID: JSD-2023-8842
Invoice Details:
Invoice Number: INV-JKT-20231024-001
Service Provider: Dr. Sarah Wijaya, Sp.KG
Insurance: BPJS Kesehatan / Private Insurance
Policy Number: INS-99887766
| Description of Dental Services | Code | Qty | Unit Price (IDR) | Total (IDR) |
|---|---|---|---|---|
| Comprehensive Dental Examination & Consultation | D0150 | 1 | 350,000 | 350,000 |
| Full Mouth Panoramic X-Ray (OPG) | D0330 | 1 | 450,000 | 450,000 |
| Professional Dental Cleaning (Scaling & Polishing) | D1110 | 1 | 750,000 | 750,000 |
| Composite Filling (Tooth #36, Class II) | D2392 | 1 | 1,200,000 | 1,200,000 |
| Root Canal Therapy (Molar, Single Visit) | D3330 | 1 | 3,500,000 | 3,500,000 |
| Porcelain Dental Crown (Zirconia) | D2750 | 1 | 4,500,000 | 4,500,000 |
| Local Anesthesia | D9920 | 2 | 100,000 | 200,000 |
| Post-Operative Medication Kit | PHARM | 1 | 150,000 | 150,000 |
Payment Instructions
Please make payment within 14 days of the invoice date to avoid late fees. Payments can be made via bank transfer to the following account:
Bank: Bank Central Asia (BCA)
Account Name: PT Jakarta Smile Dental Clinic
Account Number: 123-456-7890
Reference: INV-JKT-20231024-001
For questions regarding this invoice, please contact our billing department at [email protected] or visit our clinic in Central Jakarta.
Terms and Conditions
1. This invoice is valid for services rendered at Jakarta Smile Dental Clinic, Indonesia.
2. Late payments may incur a penalty of 2% per month.
3. Insurance claims must be submitted within 30 days of treatment.
4. All dental procedures are performed by licensed dentists in accordance with Indonesian health regulations.
5. Please retain this invoice for your records and insurance purposes.
Authorized Signature:
Dr. Sarah Wijaya, Sp.KGLead Dentist
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