Invoice Dentist in Vietnam Ho Chi Minh City –Free Word Template Download with AI
Address: 123 Nguyen Hue Boulevard, District 1, Ho Chi Minh City, Vietnam
Phone: +84 (28) 3822 1234 | Email: [email protected]
Tax Code (MST): 0312345678
License No: 12345/QĐ-SYT
Invoice Number: INV-2023-10-0054
Date of Issue: October 24, 2023
Due Date: October 24, 2023 (Paid in Full)
Payment Method: Credit Card (Visa)
BILL TO:Patient Name: Mr. John Smith
Address: 45 Vo Van Tan Street, District 3, Ho Chi Minh City, Vietnam
Phone: +84 90 123 4567
Email: [email protected]
Patient ID: P-88291
DENTAL SERVICES PROVIDED IN HO CHI MINH CITY| # | Description of Dental Procedure | Code | Date | Unit Price (VND) | Total (VND) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Dental Examination & Consultation Full oral health assessment, periodontal charting, and treatment planning consultation conducted by Dr. Nguyen Van A at our District 1 clinic. |
D0150 | Oct 24, 2023 | 1,500,000 | 1,500,000 |
| 2 |
Full Mouth Digital X-Rays (OPG & Bitewings) High-resolution panoramic and periapical radiographs to assess bone structure and tooth integrity. |
D0330 | Oct 24, 2023 | 1,200,000 | 1,200,000 |
| 3 |
Professional Dental Cleaning (Scaling & Polishing) Ultrasonic scaling to remove tartar and calculus, followed by air-polishing and fluoride treatment. |
D1110 | Oct 24, 2023 | 2,000,000 | 2,000,000 |
| 4 |
Composite Resin Filling (Tooth #14) Restoration of moderate decay on upper right first premolar using aesthetic tooth-colored composite material. |
D2391 | Oct 24, 2023 | 3,500,000 | 3,500,000 |
| 5 |
Root Canal Treatment - Single Canal (Tooth #36) Endodontic therapy for lower left first molar. Includes anesthesia, access, cleaning, shaping, and obturation. |
D3310 | Oct 24, 2023 | 8,000,000 | 8,000,000 |
| 6 |
Prescription Medication Amoxicillin 500mg (Antibiotic) and Ibuprofen 400mg (Pain Relief) dispensed by clinic pharmacy. |
RX-001 | Oct 24, 2023 | 450,000 | 450,000 |
IMPORTANT NOTES & TERMS:
1. Payment Status: This invoice has been marked as PAID in full via Credit Card ending in 4242 on the date of service.
2. Warranty: All dental restorations (fillings, crowns) performed at Saigon Precision Dental Clinic in Ho Chi Minh City come with a 12-month warranty against material defects or debonding under normal use.
3. Follow-up: Please schedule a follow-up appointment within 7 days for the root canal treatment to ensure proper healing. Contact our reception at +84 (28) 3822 1234.
4. Tax Compliance: This document serves as a valid tax invoice (Hóa đơn) compliant with the General Department of Taxation of Vietnam. Please retain this document for your records.
5. Currency: All prices are quoted in Vietnamese Dong (VND). Exchange rates for foreign currencies are subject to change and are based on the bank rate on the day of payment.
Authorized by:
Dr. Nguyen Van A
Chief Dentist
(Signature & Clinic Stamp)
Received by:
Mr. John Smith
Patient
(Signature)
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