Invoice Ophthalmologist in Indonesia Jakarta –Free Word Template Download with AI
Specialist Ophthalmology Center
Jl. Sudirman Kav. 52-53, SCBD Lot 10
Jakarta Selatan, DKI Jakarta 12190
Indonesia
Telp: +62 21 5555 8888 | Email: [email protected]
NPWP: 01.234.567.8-901.000
Professional Ophthalmologist Services
Bill To:
Mr. Budi Santoso
PT. Global Tech Indonesia
Jl. Gatot Subroto No. 10
Jakarta Pusat, DKI Jakarta 10270
Indonesia
Phone: +62 812 3456 7890
| # | Description of Ophthalmologist Services | Quantity | Unit Price (IDR) | Total (IDR) |
|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmic Examination Includes visual acuity testing, refraction, slit-lamp examination, and intraocular pressure measurement conducted by a certified Ophthalmologist in Jakarta. |
1 | 1,500,000 | 1,500,000 |
| 2 |
Advanced Retinal Imaging (OCT) Optical Coherence Tomography scan to assess retinal layers and optic nerve health, essential for diagnosing glaucoma and macular degeneration. |
1 | 2,250,000 | 2,250,000 |
| 3 |
Corneal Topography Analysis Detailed mapping of the corneal surface curvature to detect astigmatism, keratoconus, or irregularities prior to refractive surgery planning. |
1 | 1,800,000 | 1,800,000 |
| 4 |
Specialist Consultation Fee Consultation with Dr. Andi Wijaya, Sp.M (Board-Certified Ophthalmologist) for diagnosis, treatment planning, and medical advice. |
1 | 750,000 | 750,000 |
| 5 |
Prescription Medication Antibiotic eye drops (Moxifloxacin 0.5%) and lubricating eye drops prescribed for post-examination care. |
2 | 150,000 | 300,000 |
| 6 |
Medical Report Documentation Official medical report detailing findings and recommendations, formatted for insurance claims or corporate health records in Indonesia. |
1 | 200,000 | 200,000 |
Amount in words: Seven Million Five Hundred Forty-Eight Thousand Indonesian Rupiah.
Payment Instructions & Terms:
Please remit payment within 30 days of the invoice date to avoid late fees. This Invoice is issued in accordance with the tax regulations of the Republic of Indonesia.
Bank Transfer Details:
Bank: Bank Central Asia (BCA)
Account Name: PT. Mata Sehat Jakarta
Account Number: 123-456-7890
Branch: Jakarta Sudirman
For credit card payments or corporate billing inquiries, please contact our finance department at [email protected]. Please reference the Invoice Number (INV-JKT-OPHT-2023-0892) in your payment description.
Service Disclaimer:
The services rendered by our Ophthalmologist are based on the medical condition of the patient at the time of examination in Jakarta. This Invoice covers only the services listed above. Any additional procedures, surgeries, or follow-up visits will be subject to separate billing. PT. Mata Sehat Jakarta adheres to the highest standards of ophthalmic care in Indonesia.
Authorized Signature:
Dr. Andi Wijaya, Sp.MLead Ophthalmologist
PT. Mata Sehat Jakarta ⬇️ Download as DOCX Edit online as DOCX
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