Invoice Optometrist in Belgium Brussels –Free Word Template Download with AI
Dr. Jean-Pierre Dubois, Optometrist
123 Avenue Louise
1050 Brussels, Belgium
Phone: +32 2 555 1234
Email: [email protected]
VAT Number: BE0123.456.789
Enterprise Number: 0123.456.789
Invoice Number: INV-2023-10-0042
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Payment Terms: Net 30 Days
Bill To:
Mme. Sophie Laurent
45 Rue de la Loi
1040 Brussels, Belgium
National Register Number: 850101 123 45 67
Insurance: Mutualité Chrétienne
Service Location:
Brussels Vision Optometry Clinic
123 Avenue Louise
1050 Brussels, Belgium
Service Date: October 20, 2023
| # | Description of Optometry Services | Code | Qty | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|---|
| 1 | Comprehensive Eye Examination including refraction, visual acuity testing, and ocular health assessment performed by licensed Optometrist in Brussels. | OPT-EXAM-01 | 1 | 85.00 | 85.00 |
| 2 | Dilated Fundus Examination for retinal health screening and early detection of diabetic retinopathy or glaucoma. | OPT-DIL-02 | 1 | 45.00 | 45.00 |
| 3 | Precision Lens Fitting and Dispensing for Progressive Multifocal Lenses (High Index 1.67, Anti-Reflective Coating). | OPT-LENS-03 | 1 | 220.00 | 220.00 |
| 4 | Premium Titanium Eyeglass Frame (Model: Brussels Classic Series). | OPT-FRM-04 | 1 | 150.00 | 150.00 |
| 5 | Post-Dispensing Adjustment and Patient Education on lens adaptation. | OPT-ADJ-05 | 1 | 25.00 | 25.00 |
| Subtotal: | 525.00 EUR |
| VAT (21% - Standard Rate Belgium): | 110.25 EUR |
| Insurance Reimbursement Estimate (Mutualité): | -120.00 EUR |
| Total Amount Due: | 515.25 EUR |
Payment Instructions & Notes:
Please make payment within 30 days of the invoice date. Late payments may incur a statutory interest rate as per Belgian law.
Bank Transfer Details:
Bank Name: KBC Bank Brussels
Account Holder: Brussels Vision Optometry BVBA
IBAN: BE68 5390 0754 7034
BIC/SWIFT: KREDBEBB
Reference: Please use Invoice Number INV-2023-10-0042 as payment reference.
Insurance Note: This invoice is compliant with the Belgian National Institute for Health and Disability Insurance (RIZIV/INAMI) guidelines for optometry services. Please submit this document to your mutual insurance fund for reimbursement. The estimated reimbursement amount is indicative and subject to your specific insurance plan coverage.
Legal Disclaimer: This invoice is issued in accordance with the Belgian Code of Economic Law. Brussels Vision Optometry is a registered business entity operating in Brussels, Belgium. All services provided are performed by licensed Optometrists certified by the Belgian Order of Optometrists. Prices include VAT unless otherwise stated. In case of dispute, the courts of Brussels shall have jurisdiction. This document serves as a formal request for payment for professional optometry services rendered. The patient acknowledges receipt of the prescribed eyewear and understands the care instructions provided by the Optometrist.
Data Protection: Your personal data is processed in accordance with the General Data Protection Regulation (GDPR) and Belgian privacy laws. Your information is used solely for billing, medical records, and insurance purposes.
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