Invoice Optometrist in South Africa Cape Town –Free Word Template Download with AI
Dr. Sarah van der Merwe, B.Optom, M.Optom
123 Long Street, City Bowl
Cape Town, Western Cape, 8001
South Africa
Tel: +27 (0)21 555 0199
Email: [email protected]
Practice Number: 000000000
VAT Registration: 4000000000
Invoice #: INV-2023-10-045
Date: 24 October 2023
Due Date: 24 November 2023
Reference: Patient Account #88291
Bill To:
Mr. James Peterson
45 Kloof Street
Gardens, Cape Town
Western Cape, 8001
South Africa
ID Number: 850101 5000 087
Medical Aid Details:
Discovery Health
Member Number: 123456789
Plan: Momentum Health Plan
Dependent Code: 01
Claim Reference: N/A (Direct Billing)
| Description of Optometry Services | Quantity | Unit Price (ZAR) | Total (ZAR) |
|---|---|---|---|
|
Comprehensive Eye Examination Includes visual acuity testing, refraction, binocular vision assessment, and ocular health evaluation. Performed by a registered Optometrist in Cape Town. |
1 | 850.00 | 850.00 |
|
Dilated Fundus Examination Detailed examination of the retina and optic nerve using mydriatic drops. Essential for early detection of glaucoma and diabetic retinopathy. |
1 | 450.00 | 450.00 |
|
Optical Coherence Tomography (OCT) Advanced imaging of the retinal layers. Non-invasive diagnostic procedure conducted at our Cape Town facility. |
1 | 600.00 | 600.00 |
|
Pediatric Vision Screening Specialized assessment for dependent child (Age 6). Includes amblyopia screening and convergence insufficiency testing. |
1 | 700.00 | 700.00 |
|
Prescription Lenses (High Index 1.67) Pair of progressive addition lenses with anti-reflective and blue light filtering coating. Dispensed by Cape Town Clinical Optometry. |
1 | 2,400.00 | 2,400.00 |
|
Frame Selection and Adjustment Professional fitting and adjustment of titanium semi-rimless frame. Includes nose pad replacement. |
1 | 150.00 | 150.00 |
|
Contact Lens Fitting and Follow-up Initial fitting for daily disposable lenses, including corneal topography mapping and one-month follow-up consultation. |
1 | 550.00 | 550.00 |
Terms and Conditions & Payment Information
This invoice is issued by Cape Town Clinical Optometry, a registered practice operating under the Optometrists Council of South Africa (OPSA). All services rendered are performed by qualified Optometrists adhering to national standards of care.
Payment Methods: We accept EFT, credit cards (Visa, Mastercard, Amex), and debit orders. For EFT payments, please use our banking details below and quote your Invoice Number as reference.
Banking Details:
Bank: FNB Cape Town
Account Name: Cape Town Clinical Optometry (Pty) Ltd
Account Number: 62000000000
Branch Code: 250655
Medical Aid Claims: Claims are submitted directly to your medical aid provider. Please allow 10-14 business days for processing. Any shortfall between the medical aid benefit and our fees is the responsibility of the patient.
Validity: This invoice is valid for 30 days from the date of issue. Late payments may incur a monthly interest charge of 2% in accordance with South African credit practices.
Confidentiality: All patient information is handled in strict confidence in accordance with the Protection of Personal Information Act (POPIA) of South Africa.
Authorized Signature
Dr. Sarah van der Merwe
Principal Optometrist
Patient Acknowledgment
Signature: ___________________
Date: ___________________
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