Invoice Dentist in Tanzania Dar es Salaam –Free Word Template Download with AI
Specialist Dental Care in Tanzania
Plot No. 45, Sam Nujoma Road
Mikocheni, Dar es Salaam
Tanzania
Tel: +255 22 211 0000 | Email: [email protected]
TIN: 123-456-789-00-000
Invoice Number: INV-TZ-2023-0892
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Payment Status: Pending
Bill To:
Mr. John Mwangi
House No. 12, Masaki Peninsula
Dar es Salaam, Tanzania
Phone: +255 755 123 456
Email: [email protected]
Service Details:
Attending Dentist: Dr. Amina Juma
License No: TMDA-D-9988
Appointment Date: October 20, 2023
Insurance Provider: Jubilee Health (Ref: JH-998877)
| # | Description of Dental Services | Code | Quantity | Unit Price (TZS) | Total (TZS) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Dental Examination Full oral health assessment including periodontal charting and caries detection performed by a licensed dentist in Dar es Salaam. |
D0150 | 1 | 150,000 | 150,000 |
| 2 |
Full Mouth Digital X-Rays Panoramic radiography to assess bone structure and root health, compliant with Tanzania medical imaging standards. |
D0330 | 1 | 250,000 | 250,000 |
| 3 |
Professional Dental Cleaning (Prophylaxis) Scaling and polishing to remove plaque and tartar buildup, ensuring optimal gum health. |
D1110 | 1 | 100,000 | 100,000 |
| 4 |
Composite Resin Filling (Posterior) Tooth #30: Restoration of decay using high-quality aesthetic composite material. |
D2391 | 1 | 350,000 | 350,000 |
| 5 |
Root Canal Therapy (Single Root) Tooth #14: Endodontic treatment to save the natural tooth structure, performed under local anesthesia. |
D3310 | 1 | 750,000 | 750,000 |
| 6 |
Porcelain Crown Preparation Tooth #14: Preparation and temporary crown placement following root canal therapy. |
D2740 | 1 | 400,000 | 400,000 |
| 7 |
Local Anesthesia Administration of lidocaine for pain management during procedures. |
D9920 | 2 | 25,000 | 50,000 |
| 8 |
Prescription Medication Antibiotics (Amoxicillin) and Pain Relievers (Ibuprofen) for post-operative care. |
RX-001 | 1 | 45,000 | 45,000 |
Amount in words: Two Million, Four Hundred Fourteen Thousand, Three Hundred Tanzanian Shillings.
Payment Instructions
Payment is due within 14 days of the invoice date. Please include the invoice number (INV-TZ-2023-0892) as the reference for all payments.
Bank Transfer (Tanzania):
- Bank: CRDB Bank Plc
- Branch: Mikocheni, Dar es Salaam
- Account Name: Dar es Salaam Dental Clinic Ltd
- Account Number: 001234567890
- SWIFT Code: CRDBTZDX
Mobile Money:
- M-Pesa / Tigo Pesa / Airtel Money: +255 711 000 000
Cash: Accepted at the clinic reception in Dar es Salaam.
Terms and Conditions
- This invoice represents services rendered by a qualified dentist registered with the Tanzania Medical and Dental Council (TMDC).
- All prices are quoted in Tanzanian Shillings (TZS) and are inclusive of applicable taxes unless stated otherwise.
- Interest of 2% per month will be charged on overdue amounts after the due date.
- Insurance claims must be submitted within 30 days of the service date. This clinic assists with paperwork but is not responsible for insurance delays.
- Any disputes regarding this invoice must be raised in writing within 7 days of receipt.
- By accepting these services, the patient agrees to the payment terms outlined in this document.
Authorized Signature
Dr. Amina Juma
Lead Dentist
Received By
__________________________
Date: ____________________
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