Invoice Orthodontist in Australia Brisbane –Free Word Template Download with AI
Level 4, 123 Queen Street Mall
Brisbane City, QLD 4000
Australia
Phone: +61 7 3000 1234
Email: [email protected]
ABN: 12 345 678 901
Provider Number: 987654321
Invoice Number: INV-2023-8942
Date Issued: 24 October 2023
Due Date: 07 November 2023
Payment Status: Outstanding
Bill To:
Patient Name: Sarah Jane Thompson
Policy Holder: Michael Robert Thompson
Address: 45 River Terrace
South Brisbane, QLD 4101
Australia
Health Fund: Bupa Private Health Insurance
Member Number: BUP-99887766
Group Number: G-12345
Phone: 0412 345 678
Orthodontic Treatment Schedule
The following invoice details the comprehensive orthodontic care provided at our Brisbane clinic. These services include initial diagnostic assessments, the fabrication and fitting of fixed appliances, and ongoing monitoring in accordance with Australian Dental Association standards.
| Item | Description of Services | Date | Amount (AUD) | GST (10%) |
|---|---|---|---|---|
| 1 |
Initial Orthodontic Consultation & Diagnostic Records Comprehensive examination of dental alignment, occlusion analysis, and discussion of treatment options. Includes panoramic radiograph (OPG), lateral cephalometric radiograph, and intraoral photography. |
01 Oct 2023 | $350.00 | $35.00 |
| 2 |
Fixed Orthodontic Appliance (Braces) - Upper Arch Bonding of stainless steel brackets and placement of archwire. Includes all necessary bonding agents and composite materials. |
15 Oct 2023 | $2,200.00 | $220.00 |
| 3 |
Fixed Orthodontic Appliance (Braces) - Lower Arch Bonding of stainless steel brackets and placement of archwire. Includes all necessary bonding agents and composite materials. |
15 Oct 2023 | $2,200.00 | $220.00 |
| 4 |
Intermaxillary Elastics & Auxiliaries Supply of elastic bands and power chains to assist in correcting bite alignment and jaw positioning. |
15 Oct 2023 | $150.00 | $15.00 |
| 5 |
First Adjustment Appointment Initial activation of appliances, wire change, and patient education on oral hygiene maintenance specific to orthodontic treatment in Brisbane. |
22 Oct 2023 | $250.00 | $25.00 |
| Subtotal: | $5,150.00 |
| Total GST (10%): | $515.00 |
| Total Amount Due: | $5,665.00 |
Payment Instructions & Important Information
Payment Methods: We accept Bank Transfer (BSB: 082-001, Account: 12345678), Credit Card (Visa, Mastercard, Amex), and Direct Debit. Please quote the Invoice Number (INV-2023-8942) with all payments.
Health Fund Claims: As this is an orthodontic treatment invoice, please note that many Australian private health funds require pre-approval for orthodontic work. If you have not yet submitted a pre-approval request to your fund, please do so immediately. This invoice can be used to claim rebates after payment is made.
Treatment Plan: This invoice represents the initial phase of the comprehensive orthodontic treatment plan agreed upon during your consultation at our Brisbane clinic. Future adjustment appointments will be billed separately or according to the payment plan established.
Due Date: Payment is due within 14 days of the invoice date. Late payments may incur interest charges in accordance with Australian consumer law.
Authorized By:
Dr. Emily Chen
Principal Orthodontist
Brisbane Elite Orthodontics
Patient/Guardian Acknowledgement:
I acknowledge receipt of this invoice and agree to the terms of payment.
Signature: _________________________
Date: _________________________
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