Invoice Dentist in Japan Tokyo –Free Word Template Download with AI
2-14-5 Kabukicho, Shinjuku-ku, Tokyo 160-0021, Japan
Tel: +81-3-5555-0199 | Email: [email protected]
Corporate Number: T-1234567890123
Medical Institution License No.: 16B-00-001234
Official Receipt for Dental Services
Billed To:
Mr. James Anderson
1-2-3 Roppongi, Minato-ku, Tokyo 106-0032, Japan
Email: [email protected]
Phone: +81-90-1234-5678
National Health Insurance No.: N/A (Self-Pay)
| # | Description of Dental Services | Code | Unit Price (JPY) | Total (JPY) |
|---|---|---|---|---|
| 1 |
Initial Comprehensive Examination Includes oral cancer screening, periodontal charting, and consultation regarding treatment plan for crown restoration. |
101-01 | ¥5,400 | ¥5,400 |
| 2 |
Full Mouth Radiography (Panoramic X-Ray) Digital imaging required for assessment of jawbone structure and root canal history. |
202-05 | ¥3,200 | ¥3,200 |
| 3 |
Professional Dental Cleaning (Scaling & Polishing) Ultrasonic scaling and air polishing to remove tartar and plaque buildup. |
305-10 | ¥8,500 | ¥8,500 |
| 4 |
Composite Resin Filling (Tooth #36) Restoration of Class II cavity on lower left first molar using aesthetic composite material. |
410-22 | ¥12,000 | ¥12,000 |
| 5 |
Local Anesthesia Administration of lidocaine for pain management during filling procedure. |
501-01 | ¥1,500 | ¥1,500 |
| 6 |
Fluoride Treatment Application of high-concentration fluoride varnish to strengthen enamel. |
602-03 | ¥2,000 | ¥2,000 |
Terms, Conditions, and Important Information
This invoice represents the official record of dental services provided at Shinjuku Advanced Dental Clinic, located in the heart of Tokyo, Japan. As per Japanese medical billing standards, all prices listed include the necessary materials and professional fees.
Payment Status: This invoice has been marked as PAID in full via Credit Card (Visa ending in 4242) on the date of service.
Tax Information: In accordance with the Japanese Consumption Tax Act, a 10% tax has been applied to all medical services and materials provided. This rate is standard for healthcare services in Tokyo as of the current fiscal year.
Insurance Note: The patient elected to pay out-of-pocket for this visit. If you possess Japanese National Health Insurance (NHI), please present your card at the front desk during future visits to utilize the standard 30% co-pay system. Foreign visitors may be eligible for reimbursement through their home country's health insurance or private travel insurance; please retain this invoice and the attached detailed medical report for such claims.
Follow-up Care: Based on today's examination, a follow-up appointment is recommended in 6 months for routine maintenance. Please contact our reception desk in Shinjuku to schedule your next visit.
Thank you for trusting our dental team with your oral health in Tokyo.
[Official Clinic Stamp / Hanko Would Appear Here]Shinjuku Advanced Dental Clinic
Authorized Signature: Dr. Kenji Tanaka ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT