Invoice Ophthalmologist in Brazil Brasília –Free Word Template Download with AI
Specialized Ophthalmology Clinic
Address: SHIS QI 15, Conjunto 2, Casa 10, Lago Sul
Brasília, DF - Brazil, CEP: 71605-050
CNPJ: 12.345.678/0001-90
CRM-DF: 12345 | COREN-DF: 6789
Phone: +55 (61) 3333-4444
Email: [email protected]
Invoice Number: INV-2024-0892
Date Issued: October 15, 2024
Due Date: October 30, 2024
Payment Terms: Net 15 Days
Currency: Brazilian Real (BRL)
Billed To:
Patient Name: Maria Silva Santos
CPF: 123.456.789-00
Address: SIA Trecho 2, Lote 500, Asa Sul
Brasília, DF - Brazil, CEP: 71200-030
Phone: +55 (61) 99999-8888
Email: [email protected]
Insurance Provider: Unimed Brasília
Policy Number: UNI-789456123
Professional Ophthalmology Services Rendered
This invoice details the comprehensive ophthalmological services provided by our licensed ophthalmologist at our Brasília clinic. All procedures were conducted in accordance with Brazilian medical standards and regulations established by the Federal Council of Medicine (CFM).
| Service Description | Procedure Code | Date of Service | Quantity | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|
| Comprehensive Ophthalmological Examination including visual acuity testing, refraction assessment, and ocular health evaluation | 92004.00-0 | October 10, 2024 | 1 | R$ 350.00 | R$ 350.00 |
| Dilated Fundus Examination with detailed retinal assessment using advanced imaging technology | 92250.00-0 | October 10, 2024 | 1 | R$ 280.00 | R$ 280.00 |
| Optical Coherence Tomography (OCT) - Macula and Optic Nerve Analysis | 92134.00-0 | October 10, 2024 | 1 | R$ 450.00 | R$ 450.00 |
| Visual Field Testing (Perimetry) - Automated Computerized Test | 92083.00-0 | October 10, 2024 | 1 | R$ 320.00 | R$ 320.00 |
| Corneal Topography Mapping for precise refractive assessment | 92131.00-0 | October 10, 2024 | 1 | R$ 380.00 | R$ 380.00 |
| Prescription for corrective lenses including detailed specifications for progressive multifocal lenses | 92015.00-0 | October 10, 2024 | 1 | R$ 150.00 | R$ 150.00 |
| Medical consultation for glaucoma monitoring and management plan development | 92002.00-0 | October 10, 2024 | 1 | R$ 400.00 | R$ 400.00 |
| Prescription medication for ocular condition management (IOP-lowering drops) | 99999.00-0 | October 10, 2024 | 1 | R$ 180.00 | R$ 180.00 |
| Subtotal: | R$ 2,510.00 |
| Insurance Coverage (Unimed Brasília): | -R$ 1,800.00 |
| Patient Responsibility: | R$ 710.00 |
| TOTAL DUE: | R$ 710.00 |
Important Notes and Payment Information:
Payment Methods Accepted: Bank transfer (TED/DOC), PIX (Brazilian instant payment system), credit card (up to 3 installments without interest), or cash payment at our Brasília clinic reception.
PIX Key: [email protected]
Bank Details: Banco do Brasil, Agency: 1234-5, Account: 67890-1
Please include the invoice number (INV-2024-0892) as payment reference. Late payments may incur a 2% monthly interest charge in accordance with Brazilian commercial law.
This invoice is valid for tax purposes in Brazil. All services were performed by a licensed ophthalmologist registered with the Federal Council of Medicine (CFM) and the Regional Medical Council of the Federal District (CRM-DF).
For questions regarding this invoice or your ophthalmological care, please contact our billing department during business hours (Monday to Friday, 8:00 AM to 6:00 PM Brasília time).
Authorized by:
Dr. Ricardo Mendes Oliveira
Ophthalmologist - CRM-DF: 12345
Brasília Vision Care Center
Patient Acknowledgment:
Maria Silva Santos
Date: _______________
Signature: _______________
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