Invoice Dentist in South Africa Cape Town –Free Word Template Download with AI
123 Long Street, City Bowl
Cape Town, Western Cape, 8001
South Africa
Tel: +27 (0)21 555 1234
Email: [email protected]
HPCSA Reg: 2023456789
Invoice Number: INV-CT-2024-0892
Date Issued: 15 October 2024
Due Date: 15 November 2024
Payment Reference: INV-CT-2024-0892
Bill ToMr. James van der Merwe
45 Kloof Street
Gardens, Cape Town
Western Cape, 8001
South Africa
ID Number: 850101 5000 087
Medical Aid: Discovery Health
Member Number: DIS-987654321
Pay FromCape Town Dental Specialists
Bank: First National Bank
Account Name: CT Dental Specialists (Pty) Ltd
Account Number: 62045678901
Branch Code: 250655
Account Type: Business Cheque
SWIFT Code: FIRNZAJJ
Important Notice for South African Patients: This invoice reflects services rendered in accordance with the Health Professions Council of South Africa (HPCSA) guidelines. Please submit this document to your medical aid scheme for reimbursement where applicable. Payment is due within 30 days of the invoice date. Late payments may incur interest at the prescribed rate. Description of Dental Services Rendered| Item | Description | Date | Code | Amount (ZAR) |
|---|---|---|---|---|
| 1 | Comprehensive dental examination and consultation including oral cancer screening and periodontal assessment | 10 Oct 2024 | 0110 | R 650.00 |
| 2 | Full mouth radiographic examination (OPG and bitewings) for diagnostic purposes | 10 Oct 2024 | 0220 | R 1,200.00 |
| 3 | Professional teeth cleaning (scaling and polishing) - upper and lower arch | 10 Oct 2024 | 0310 | R 950.00 |
| 4 | Composite filling on tooth #36 (lower left first molar) - moderate cavity | 12 Oct 2024 | 0420 | R 1,800.00 |
| 5 | Root canal treatment on tooth #14 (upper right first premolar) - single canal | 14 Oct 2024 | 0510 | R 3,500.00 |
| 6 | Porcelain crown preparation and temporary crown placement on tooth #14 | 14 Oct 2024 | 0610 | R 4,200.00 |
| 7 | Follow-up consultation and assessment of healing post-root canal treatment | 15 Oct 2024 | 0110 | R 450.00 |
Terms and Conditions
1. This invoice is issued in accordance with the South African National Credit Act and relevant healthcare regulations.
2. Payment is due within 30 days from the date of issue. Please use the invoice number as your payment reference.
3. VAT is charged at the standard rate of 15% as per South African Revenue Service (SARS) regulations.
4. Medical aid claims are submitted on behalf of the patient where applicable. The estimated contribution is based on current scheme benefits and is subject to change.
5. Any disputes regarding this invoice must be raised in writing within 14 days of receipt.
6. Cape Town Dental Specialists is committed to providing high-quality dental care in compliance with HPCSA standards.
7. For queries regarding this invoice, please contact our billing department at [email protected] or call +27 (0)21 555 1234.
8. This document serves as an official record of dental services provided and may be required for tax or insurance purposes.
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