Invoice Dentist in Saudi Arabia Jeddah –Free Word Template Download with AI
Al Rawdah District, Jeddah, Saudi Arabia
P.O. Box: 12345 | Zip Code: 21442
Phone: +966 12 345 6789
Email: [email protected]
VAT Registration Number: 300123456700003
Commercial Registration: 1010023456
Invoice Number: INV-2024-0892
Date of Issue: January 15, 2024
Due Date: February 15, 2024
Payment Terms: Net 30 Days
Billed To:
Patient Name: Ahmed Mohammed Al-Saud
National ID: 1098765432
Address: Al Hamra District, Jeddah, Saudi Arabia
Phone: +966 55 123 4567
Email: [email protected]
Insurance Provider: Bupa Arabia (Policy #BP-2024-7890)
Professional Dental Services Rendered
This invoice represents the comprehensive dental care services provided at our Jeddah facility in accordance with the standards set by the Saudi Commission for Health Specialties (SCFHS). All procedures were performed by licensed dental professionals registered in Saudi Arabia.
| Item # | Description of Dental Service | Procedure Code | Date of Service | Quantity | Unit Price (SAR) | Total (SAR) |
|---|---|---|---|---|---|---|
| 1 | Comprehensive Dental Examination and Consultation | D0150 | Jan 10, 2024 | 1 | 350.00 | 350.00 |
| 2 | Full Mouth Digital X-Rays (Panoramic) | D0330 | Jan 10, 2024 | 1 | 450.00 | 450.00 |
| 3 | Professional Dental Cleaning (Prophylaxis) | D1110 | Jan 10, 2024 | 1 | 500.00 | 500.00 |
| 4 | Composite Filling - Posterior Tooth (Tooth #30) | D2392 | Jan 12, 2024 | 1 | 800.00 | 800.00 |
| 5 | Root Canal Therapy - Single Root (Tooth #14) | D3310 | Jan 14, 2024 | 1 | 2,500.00 | 2,500.00 |
| 6 | Dental Crown - Porcelain Fused to Metal (Tooth #14) | D2750 | Jan 14, 2024 | 1 | 3,200.00 | 3,200.00 |
| 7 | Local Anesthesia Administration | D9920 | Jan 12, 2024 | 2 | 150.00 | 300.00 |
| 8 | Follow-up Consultation and Treatment Assessment | D0140 | Jan 15, 2024 | 1 | 250.00 | 250.00 |
| Subtotal: | 8,350.00 SAR |
| VAT (15%): | 1,252.50 SAR |
| TOTAL AMOUNT DUE: | 9,602.50 SAR |
* VAT calculated in accordance with Saudi Arabian tax regulations. VAT Registration Number: 300123456700003
Important Notes and Terms:
- This invoice is issued in compliance with the Zakat, Tax and Customs Authority (ZATCA) regulations in Saudi Arabia.
- Payment is expected within 30 days from the date of invoice issuance.
- Late payments may incur a penalty of 2% per month on the outstanding balance.
- Accepted payment methods: Bank Transfer (STC Pay, Apple Pay), Credit/Debit Cards, Cash (SAR).
- For insurance claims, please submit this invoice along with the treatment plan and medical reports to your insurance provider.
- All dental procedures were performed following the guidelines of the Saudi Dental Association and SCFHS standards.
- Please retain this invoice for your records and for any warranty claims related to dental work performed.
- For any questions regarding this invoice, please contact our billing department at +966 12 345 6789 or email [email protected].
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