Invoice Dentist in Philippines Manila –Free Word Template Download with AI
License No.: PRC-12345678
Business Permit: City of Manila - 2024-001234
TIN: 123-456-789-000
123 Rizal Avenue, Ermita
Manila, Philippines 1000
Tel: +63 2 8123 4567
Email: [email protected]
Invoice No.: INV-2024-00567
Date Issued: January 15, 2024
Due Date: February 15, 2024
Payment Status: Pending
Bill To:
Patient Name: Maria Santos Cruz
Address: 456 Makati Avenue, Makati City, Metro Manila, Philippines
Contact Number: +63 917 123 4567
Email: [email protected]
Insurance Provider: PhilHealth / Maxicare (if applicable)
Policy Number: MC-987654321
| Item No. | Description of Dental Services | Quantity | Unit Price (PHP) | Total Amount (PHP) |
|---|---|---|---|---|
| 1 | Comprehensive Dental Examination and Consultation | 1 | 1,500.00 | 1,500.00 |
| 2 | Full Mouth Panoramic X-Ray (OPG) | 1 | 2,000.00 | 2,000.00 |
| 3 | Professional Dental Cleaning (Scaling and Polishing) | 1 | 3,500.00 | 3,500.00 |
| 4 | Composite Filling - Upper Right Molar (Tooth #3) | 1 | 4,500.00 | 4,500.00 |
| 5 | Root Canal Treatment - Lower Left Premolar (Tooth #20) | 1 | 12,000.00 | 12,000.00 |
| 6 | Porcelain Crown - Lower Left Premolar (Tooth #20) | 1 | 15,000.00 | 15,000.00 |
| 7 | Temporary Crown Placement | 1 | 1,500.00 | 1,500.00 |
| 8 | Follow-up Consultation and Adjustment | 2 | 1,000.00 | 2,000.00 |
| 9 | Prescription Medications (Antibiotics and Pain Relievers) | 1 | 800.00 | 800.00 |
| 10 | Dental Sealants - Upper Molars (Preventive Care) | 4 | 500.00 | 2,000.00 |
Payment Terms and Conditions
Payment Due: Payment is due within 30 days from the date of invoice issuance. Late payments may incur a 1.5% monthly interest charge as per Philippine regulations.
Accepted Payment Methods:
- Cash (Philippine Peso)
- Bank Transfer: BDO Unibank, Account Name: Manila Premier Dental Clinic, Account No. 1234-5678-9012
- Credit/Debit Cards: Visa, Mastercard, UnionPay
- GCash/Maya: +63 917 123 4567
Insurance Claims: For patients with dental insurance coverage, please submit this invoice along with your treatment plan and receipts to your insurance provider. Our clinic can assist with filing claims for PhilHealth-accredited procedures.
Receipt: An official receipt will be issued upon full payment as required by the Bureau of Internal Revenue (BIR) of the Philippines.
Important Notes
This invoice represents the professional dental services rendered by Manila Premier Dental Clinic, a licensed dental practice operating in Manila, Philippines. All treatments were performed in accordance with the standards set by the Philippine Dental Association and the Professional Regulation Commission (PRC).
Please retain this invoice for your records and for any insurance reimbursement purposes. If you have any questions regarding this invoice or the services provided, please contact our billing department at +63 2 8123 4567 or email [email protected].
Thank you for choosing Manila Premier Dental Clinic for your oral health care needs. We are committed to providing excellent dental services to our patients in Manila and throughout the Philippines.
Authorized by:
Dr. Roberto M. Reyes, DDS
Lead Dentist
PRC License No. 123456
Received by:
Patient Signature
Date: _______________
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