Invoice Optometrist in Brazil São Paulo –Free Word Template Download with AI
Optometry & Ophthalmology Clinic
Av. Paulista, 1578 - Bela Vista
São Paulo - SP, 01310-200
Brazil
CNPJ: 12.345.678/0001-90
CREO-SP: 12345
Phone: +55 (11) 3254-8899
Email: [email protected]
Invoice Number: INV-2023-SP-8942
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Service Period: October 2023
Payment Status: Pending
Bill To:
Roberto Almeida Silva
Rua Augusta, 1200 - Consolação
São Paulo - SP, 01304-001
Brazil
CPF: 123.456.789-00
Email: [email protected]
Insurance / Third Party Payer:
Unimed São Paulo
Policy Number: UP-99887766
Group: Corporate Executive Plan
Authorization Code: AUT-SP-55432
| # | Description of Services | Code (CBHPM) | Qty | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Optometric Examination Includes visual acuity testing, refraction, binocular vision assessment, and ocular health evaluation. Performed by licensed Optometrist in São Paulo. |
30101 | 1 | R$ 250,00 | R$ 250,00 |
| 2 |
Dilated Fundus Examination Detailed inspection of the retina, optic nerve, and macula using mydriatic drops. Essential for early detection of glaucoma and diabetic retinopathy. |
30105 | 1 | R$ 180,00 | R$ 180,00 |
| 3 |
Corneal Topography Mapping Advanced digital mapping of the corneal surface curvature. Required for precise contact lens fitting and pre-surgical evaluation. |
30112 | 1 | R$ 320,00 | R$ 320,00 |
| 4 |
Custom Contact Lens Fitting & Dispensing Professional fitting of toric soft contact lenses for astigmatism correction. Includes trial lenses, follow-up adjustment, and patient education. |
30120 | 1 | R$ 450,00 | R$ 450,00 |
| 5 |
Prescription Eyewear Dispensing Supply of high-index anti-reflective lenses and titanium frame. Includes precise optical centering and frame adjustment by optician. |
30135 | 1 | R$ 1.200,00 | R$ 1.200,00 |
| 6 |
Low Vision Rehabilitation Consultation Specialized assessment and prescription of optical aids for patients with reduced visual acuity not correctable by standard means. |
30140 | 1 | R$ 350,00 | R$ 350,00 |
Payment Instructions
Please remit payment within 14 days of the invoice date to avoid late fees. Payments can be made via bank transfer (TED/DOC) or PIX.
Bank: Banco do Brasil
Agency: 1234-5
Account: 98765-4
Account Holder: Vision Care São Paulo Ltda.
PIX Key: [email protected]
Reference: INV-2023-SP-8942
Terms and Conditions
1. This invoice represents professional optometric services rendered in accordance with the regulations of the Conselho Regional de Óptica e Optometria de São Paulo (CREO-SP).
2. All prices are quoted in Brazilian Reais (BRL). Taxes are calculated based on current São Paulo state legislation.
3. Insurance claims are processed directly with the provider. The patient is responsible for any co-payments or non-covered services as indicated above.
4. Late payments will incur a penalty of 2% plus interest of 1% per month, as per Brazilian commercial law.
5. Please retain this document for your records and for any potential reimbursement claims.
6. For questions regarding this invoice, please contact our billing department at +55 (11) 3254-8899.
Authorized Signature
Dr. Carlos Mendes
Lead Optometrist
Vision Care São Paulo
PAID
Date: _______________
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