Invoice Dentist in Senegal Dakar –Free Word Template Download with AI
Dr. Aminata Diop, DDS
12 Avenue Cheikh Anta Diop, Sacré-Cœur
Dakar, Senegal
Tel: +221 33 825 12 34
Email: [email protected]
Registre de Commerce: RM-DKR-2023-4589
ICE: SN-987654321000
Invoice #: INV-2023-10-045
Date: October 24, 2023
Due Date: November 07, 2023
Currency: XOF (West African CFA Franc)
Bill To:
Monsieur Moussa Ndiaye
45 Rue de Thiong, Almadies
Dakar, Senegal
Phone: +221 77 654 32 10
Email: [email protected]
Insurance / Payment Info:
Insurance Provider: CNPS / Mutualité
Policy Number: CNPS-8842-SENEGAL
Reference: Dental Plan Premium
| # | Description of Dental Services | Date of Service | Qty | Unit Price (XOF) | Total (XOF) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Dental Examination & Consultation Initial assessment of oral health, periodontal charting, and treatment planning discussion conducted at our Dakar clinic. |
Oct 24, 2023 | 1 | 25,000 | 25,000 |
| 2 |
Full Mouth Panoramic X-Ray Digital radiographic imaging to assess bone structure and tooth alignment. |
Oct 24, 2023 | 1 | 30,000 | 30,000 |
| 3 |
Professional Dental Cleaning (Prophylaxis) Ultrasonic scaling and polishing to remove plaque and tartar buildup. |
Oct 24, 2023 | 1 | 45,000 | 45,000 |
| 4 |
Composite Resin Filling (Tooth #14) Restoration of decayed tooth using tooth-colored composite material. |
Oct 24, 2023 | 1 | 60,000 | 60,000 |
| 5 |
Root Canal Therapy (Tooth #36) Endodontic treatment to remove infected pulp, clean canals, and seal the tooth. |
Oct 24, 2023 | 1 | 150,000 | 150,000 |
| 6 |
Prescription Medication Antibiotics and pain management medication prescribed post-procedure. |
Oct 24, 2023 | 1 | 15,000 | 15,000 |
| Subtotal: | 325,000 XOF |
| Discount (Insurance Coverage): | -100,000 XOF |
| Net Amount: | 225,000 XOF |
| VAT (18%): | 40,500 XOF |
| TOTAL DUE: | 265,500 XOF |
Terms, Conditions, and Payment Instructions
1. Payment Methods: Payment for this invoice can be made via bank transfer to our account at Ecobank Senegal (IBAN: SN00 1100 1010 0101 0101 0101 010), mobile money (Wave/Orange Money to +221 77 000 00 00), or cash at our reception in Dakar. Please reference Invoice #INV-2023-10-045 with all payments.
2. Due Date: The total amount of 265,500 XOF is due within 14 days of the invoice date. Late payments may incur a penalty fee of 5% per month on the outstanding balance, in accordance with Senegalese commercial regulations.
3. Insurance Claims: If you are submitting this invoice to your insurance provider (e.g., CNPS, Mutuelle), please ensure you attach the detailed clinical report provided separately. Our clinic is registered to accept direct billing for select insurance plans in Senegal.
4. Follow-up Care: As part of our commitment to your dental health in Dakar, a follow-up appointment is recommended two weeks after the root canal therapy. Please contact our scheduling team to book this visit.
5. Disputes: Any discrepancies regarding the services rendered or charges listed on this invoice must be reported within 7 days of receipt. Please contact our billing department directly.
6. Legal Compliance: This invoice is issued in compliance with the tax laws of the Republic of Senegal. The VAT number and registration details listed above are valid for fiscal purposes.
Authorized Signature
Dr. Aminata Diop
Lead Dentist
Received By
M. Moussa Ndiaye
Date: _______________
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