Invoice Dentist in Peru Lima –Free Word Template Download with AI
Specialized Dental Clinic
Av. Javier Prado Este 4500, San Isidro
Lima, Peru - Postal Code: 15046
RUC: 20601234567
Phone: +51 (1) 456-7890
Email: [email protected]
Invoice Number: E-001-045892
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Bill To:
Mr. Carlos Alberto Mendoza Ruiz
DNI: 45678912
Av. Arequipa 1234, Of. 501, Miraflores
Lima, Peru
Email: [email protected]
Phone: +51 987 654 321
| Patient Name: Carlos Alberto Mendoza Ruiz | Treatment Plan ID: TP-2023-889 |
| Attending Dentist: Dr. Sofia Valenzuela (Lic. 12345) | Insurance Provider: None (Direct Payment) |
Services Rendered
The following dental procedures were performed at our clinic in Lima, Peru, in accordance with the agreed treatment plan and local health regulations.
| Code | Description of Dental Service | Qty | Unit Price (PEN) | Total (PEN) |
|---|---|---|---|---|
| D0150 | Comprehensive Oral Evaluation and Diagnostic Imaging (X-Rays) | 1 | 150.00 | 150.00 |
| D1110 | Prophylaxis: Adult Dental Cleaning and Scaling | 1 | 200.00 | 200.00 |
| D2391 | Direct Composite Resin Restoration (Anterior Tooth) | 2 | 350.00 | 700.00 |
| D2750 | Amalgam Restoration (Posterior Tooth) - High Strength | 1 | 280.00 | 280.00 |
| D3330 | Direct Pulp Capping Procedure (Vital Pulp Therapy) | 1 | 450.00 | 450.00 |
| D9110 | Local Anesthesia: Infiltration for Dental Procedures | 3 | 25.00 | 75.00 |
| D9910 | Emergency Dental Visit Fee (Urgent Care in Lima) | 1 | 100.00 | 100.00 |
| D9940 | Prescription Medication: Antibiotics and Analgesics | 1 | 60.00 | 60.00 |
| Subtotal: | S/ 2,015.00 |
| IGV (18% VAT): | S/ 362.70 |
| Total Amount Due: | S/ 2,377.70 |
Terms and Conditions
1. This invoice is issued in accordance with the tax regulations of the Republic of Peru. Payment is due within 30 days from the date of issue.
2. All dental services listed above were performed by licensed professionals at our clinic in Lima, Peru. We adhere to the highest standards of dental care and hygiene.
3. Prices are quoted in Peruvian Soles (PEN). Late payments may incur a penalty fee of 1.5% per month on the outstanding balance.
4. Please retain this invoice for your records and for any potential insurance reimbursement claims. Our clinic accepts bank transfers, credit cards, and cash payments.
5. For any questions regarding this invoice or your dental treatment, please contact our billing department at [email protected] or call +51 (1) 456-7890.
6. This document serves as an official receipt for the dental services rendered. Thank you for choosing Sonrisa Integral Lima for your oral health needs.
Authorized Signature
Dr. Sofia Valenzuela
Lead Dentist
Received By
Carlos Alberto Mendoza Ruiz
Date: _______________
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