Invoice Optometrist in Canada Toronto –Free Word Template Download with AI
Dr. Sarah Jenkins, O.D.
Registered Optometrist in Ontario
123 Bay Street, Suite 400
Toronto, Ontario, Canada M5J 2R8
Phone: (416) 555-0199
Email: [email protected]
HST#: 123456789RT0001
Invoice Number: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 24, 2023
Bill To:
Mr. James Anderson
456 King Street West
Toronto, Ontario, Canada M5V 1K1
Phone: (647) 555-0123
Email: [email protected]
Insurance / Third Party Payer:
Royal Sun Alliance Insurance
Policy Number: RSA-99887766
Member ID: 123456789
Group Number: G-554433
Claims Dept: Toronto Regional Office
| # | Description of Services / Products | Quantity | Unit Price (CAD) | Total (CAD) |
|---|---|---|---|---|
| 1 |
Comprehensive Eye Examination Includes visual acuity testing, refraction, ocular health assessment, and intraocular pressure measurement. Performed by a licensed Optometrist in Toronto. |
1 | $150.00 | $150.00 |
| 2 |
Dilated Fundus Examination Advanced retinal imaging and dilation to assess posterior segment health. Essential for diabetic screening and glaucoma detection. |
1 | $75.00 | $75.00 |
| 3 |
Premium Anti-Reflective Coated Lenses High-index 1.67 lenses with blue light filtering technology. Custom ground for prescription accuracy. |
1 Pair | $320.00 | $320.00 |
| 4 |
Designer Titanium Eyeglass Frames Brand: Luxottica. Model: Titanium Flex. Includes adjustment and fitting service. |
1 | $280.00 | $280.00 |
| 5 |
Contact Lens Fitting & Evaluation Initial fitting for daily disposable lenses. Includes follow-up appointment within 30 days. |
1 | $100.00 | $100.00 |
| 6 |
Prescription Contact Lenses (30-Day Supply) Brand: Acuvue Oasys. Box of 30 lenses. |
1 Box | $65.00 | $65.00 |
| Subtotal: | $990.00 |
| Harmonized Sales Tax (HST) 13%: | $128.70 |
| Insurance Coverage Applied: | -$450.00 |
| Total Amount Due: | $668.70 |
Important Notes & Terms of Service
Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. Please make cheques payable to "Toronto Vision Care Centre" or pay via credit card (Visa, MasterCard, Amex accepted).
Insurance Claims: This invoice has been prepared in accordance with the standards set by the College of Optometrists of Ontario. If your insurance requires additional documentation, please contact our billing department. We accept direct billing for most major Canadian insurance providers.
Optometry Services: All eye examinations are conducted by Dr. Sarah Jenkins, a fully licensed Optometrist in Toronto, Canada. Our clinic adheres to the highest standards of patient care and privacy as mandated by Ontario health regulations.
Warranty: All frames and lenses come with a 12-month warranty against manufacturing defects. This warranty does not cover damage due to misuse or normal wear and tear. Please retain this invoice as proof of purchase.
Privacy Policy: Your personal health information is protected under the Personal Health Information Protection Act (PHIPA) of Ontario. We ensure that all data is handled with strict confidentiality.
Contact Us: For any questions regarding this invoice or your eye care needs, please do not hesitate to contact us at (416) 555-0199 or visit our clinic in downtown Toronto.
Authorized Signature:
Dr. Sarah Jenkins, O.D.Received By:
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