Invoice Ophthalmologist in Senegal Dakar –Free Word Template Download with AI
Dr. Awa Diop, MD, PhD
Board-Certified Ophthalmologist
12 Avenue Cheikh Anta Diop, Sacré-Cœur
Dakar, Senegal
Tel: +221 33 869 12 34
Email: [email protected]
RC: DKR-B-2023-4589 | NINEA: 001234567890
Invoice Number: INV-2023-10-089
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Payment Reference: REF-DKR-OPHT-992
Billed To (Insurance / Patient)
Mr. Ibrahima Ndiaye
45 Rue de Thiong, Almadies
Dakar, Senegal
Phone: +221 77 123 45 67
Email: [email protected]
Patient Details
Name: Mr. Ibrahima Ndiaye
Date of Birth: March 15, 1978
Insurance Provider: CNPS / Mutualité
Policy Number: CNPS-SE-889210
Service Date: October 20, 2023
| # | Description of Ophthalmological Services | Code | Qty | Unit Price (XOF) | Total (XOF) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmological Consultation Initial assessment of visual acuity, ocular health evaluation, and diagnosis of presbyopia and early-stage cataracts. Includes review of medical history specific to diabetic retinopathy risks. |
OPH-001 | 1 | 35,000 | 35,000 |
| 2 |
Dilated Fundus Examination Pharmacological dilation of pupils to examine the retina, optic nerve, and macula. Essential for monitoring diabetic eye health in patients residing in the Dakar region. |
OPH-005 | 1 | 25,000 | 25,000 |
| 3 |
Optical Coherence Tomography (OCT) Advanced imaging of the retinal layers to detect macular edema. Performed using state-of-the-art equipment available at our Dakar clinic. |
OPH-012 | 1 | 60,000 | 60,000 |
| 4 |
Prescription Eyewear Dispensing Provision of anti-reflective coated lenses and titanium frames. Includes precise measurement and fitting for progressive lenses to correct presbyopia. |
OPT-008 | 1 | 120,000 | 120,000 |
| 5 |
Therapeutic Eye Drops Prescription for lubricating eye drops and anti-inflammatory medication to manage dry eye syndrome exacerbated by local environmental conditions. |
PHR-003 | 2 | 8,500 | 17,000 |
| 6 |
Follow-up Consultation Fee Scheduled review appointment to assess healing and visual adaptation to new prescription. Includes adjustment of eyewear if necessary. |
OPH-002 | 1 | 20,000 | 20,000 |
Payment Instructions and Terms
This invoice is issued in accordance with the healthcare regulations of Senegal. Payment is due within 30 days of the invoice date. Please make payments in West African CFA Francs (XOF).
Bank Transfer Details:
Bank: Ecobank Senegal
Account Name: Dakar Vision Specialists SARL
Account Number: 0012345678901234
IBAN: SN00 0110 0001 2345 6789 0123 456
SWIFT/BIC: ECOBSNSN
Cash/Mobile Money:
Payments can be made at our clinic in Dakar or via Orange Money/Wave using the reference number provided above.
Important Note:
Please retain this invoice for your personal records and for submission to your insurance provider if required.
Any discrepancies must be reported within 15 days. Late payments may incur a penalty fee of 5% per month.
Authorized Signature
Dr. Awa DiopLead Ophthalmologist
Dakar Vision Specialists ⬇️ Download as DOCX Edit online as DOCX
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