Invoice Dentist in Russia Saint Petersburg –Free Word Template Download with AI
Professional Dental Care in Saint Petersburg
Address: Nevsky Prospect, 125, Building 3, Saint Petersburg, 191025, Russia
Phone: +7 (812) 555-01-23
Email: [email protected]
INN: 7801234567 | KPP: 780101001 | OGRN: 1157847001234
Invoice Number: INV-2024-SPB-0892
Date Issued: November 15, 2024
Due Date: November 30, 2024
Currency: Russian Rubles (RUB)
Bill To:
Patient Name: Alexander Petrovich Volkov
Address: Fontanka Embankment, 42, Apt. 15
City: Saint Petersburg, 191186, Russia
Phone: +7 (921) 555-78-90
Email: [email protected]
Policy Number: MED-SPB-445821
Treatment Details:
Treatment Plan ID: TP-2024-0345
Lead Dentist: Dr. Elena Mikhailovna Sokolova
Specialization: Orthodontics & Prosthodontics
Clinic Location: Nevsky Prospect Branch
Treatment Period: October 2024 - December 2024
Next Appointment: November 22, 2024, 14:00
| # | Description of Dental Services | Quantity | Unit Price (RUB) | Total (RUB) |
|---|---|---|---|---|
| 1 | Initial Comprehensive Dental Examination and Consultation in Saint Petersburg Clinic | 1 | 4,500.00 | 4,500.00 |
| 2 | Full-Mouth Panoramic X-Ray and 3D CBCT Scan for Treatment Planning | 1 | 7,800.00 | 7,800.00 |
| 3 | Professional Dental Cleaning (Ultrasonic Scaling and Air Flow Polishing) | 1 | 6,200.00 | 6,200.00 |
| 4 | Root Canal Treatment - Molar Tooth #36 (Endodontic Therapy) | 1 | 18,500.00 | 18,500.00 |
| 5 | Zirconia Dental Crown Fabrication and Placement - Tooth #36 | 1 | 28,000.00 | 28,000.00 |
| 6 | Composite Resin Filling - Premolar Tooth #24 (Aesthetic Restoration) | 1 | 9,500.00 | 9,500.00 |
| 7 | Orthodontic Braces Installation - Upper Arch (Metallic System) | 1 | 45,000.00 | 45,000.00 |
| 8 | Orthodontic Braces Installation - Lower Arch (Metallic System) | 1 | 45,000.00 | 45,000.00 |
| 9 | Monthly Orthodontic Adjustment and Monitoring Session | 3 | 3,500.00 | 10,500.00 |
| 10 | Local Anesthesia and Pain Management Medications | 4 | 1,200.00 | 4,800.00 |
| 11 | Post-Treatment Care Kit (Toothbrush, Floss, Antiseptic Rinse) | 1 | 2,500.00 | 2,500.00 |
| 12 | Emergency Dental Consultation Fee (November 8, 2024) | 1 | 3,000.00 | 3,000.00 |
Payment Information
Bank Name: Sberbank of Russia, Saint Petersburg Branch Account Name: Neva Dental Clinic LLC Account Number: 40702810938000123456 BIC/SWIFT: 044525225 / SABRRUMM Correspondent Account: 30101810400000000225 Payment Reference: INV-2024-SPB-0892Important Notes and Terms
1. This invoice is issued in accordance with the Federal Law of the Russian Federation on Consumer Rights Protection and the regulations governing medical services in Saint Petersburg.
2. Payment is due within 15 days from the date of invoice issuance. Late payments may incur a penalty fee of 0.1% per day on the outstanding amount.
3. All dental procedures listed have been performed by licensed dentists registered with the Ministry of Health of the Russian Federation.
4. Insurance coverage has been applied based on the terms of your policy with the insurance provider. Please verify coverage details with your insurance company.
5. Orthodontic treatment requires regular monthly adjustments. Additional invoices will be issued for each adjustment session as per the treatment plan.
6. Warranty: All dental crowns and restorations come with a 2-year warranty against manufacturing defects. Orthodontic appliances are covered for 1 year.
7. For any questions regarding this invoice or your dental treatment in Saint Petersburg, please contact our billing department at [email protected] or call +7 (812) 555-01-23.
8. This document serves as an official receipt for tax purposes in the Russian Federation. Please retain this invoice for your records.
Authorized Signature Dr. Elena M. Sokolova Chief Dentist OFFICIAL CLINICSTAMP AREA Neva Dental Clinic LLC Saint Petersburg, Russia Patient Signature Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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