Invoice Dentist in Iran Tehran –Free Word Template Download with AI

Bill To:

Patient Name: Mr. Ali Rezaei

Address: No. 15, Enghelab Avenue, Zone 1, Tehran, Iran

Phone: +98 912 345 6789

National ID: 0012345678

Insurance: Iran Insurance Company - Policy #IRN-2024-5678

Item #	Description	Quantity	Unit Price (IRR)	Total (IRR)
1	Comprehensive Dental Examination and Consultation	1	500,000	500,000
2	Full Mouth Panoramic X-Ray	1	350,000	350,000
3	Professional Teeth Cleaning (Scaling and Polishing)	1	1,200,000	1,200,000
4	Composite Filling - Upper Right Molar	1	2,500,000	2,500,000
5	Root Canal Treatment - Lower Left Premolar	1	8,000,000	8,000,000
6	Dental Crown - Zirconia Material	1	12,000,000	12,000,000
7	Follow-up Consultation Visit	1	300,000	300,000
8	Prescription Medications (Antibiotics and Pain Relief)	1	450,000	450,000

Subtotal: 25,300,000 IRR Insurance Coverage (40%): -10,120,000 IRR Patient Responsibility: 15,180,000 IRR Discount (Loyalty Program): -759,000 IRR Total Amount Due: 14,421,000 IRR

Important Notes and Terms:

1. This invoice is issued in accordance with the regulations of the Iranian Ministry of Health and Medical Education.

2. Payment is due within 15 days from the date of this invoice. Late payments may incur a 2% monthly interest charge.

3. Insurance claims have been processed according to the coverage limits of Iran Insurance Company.

4. All dental procedures were performed by licensed dentists registered with the Tehran Dental Association.

5. For any questions regarding this invoice, please contact our billing department at +98 21 2200 3344.

6. This document serves as an official receipt for tax and insurance purposes in Iran.

7. Please retain this invoice for your records and future reference.

Authorized Signature

Dr. Maryam Hosseini

Chief Dentist

Patient Signature

_______________________

Date: _________________

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