Invoice Orthodontist in Belgium Brussels –Free Word Template Download with AI

Billed To (Parent/Guardian)

Mr. Thomas & Mrs. Sarah Vandenberghe

Rue de la Loi 155

1040 Brussels, Belgium

National Registry Number: 890512 123 45

Patient Details

Lucas Vandenberghe

Date of Birth: 12 May 2010

INAMI/RIZIV Number: 2 8905121 2345 67

Insurance: Mutualité Chrétienne / Christelijke Mutualiteit

Code	Description of Orthodontic Services	Qty	Unit Price (€)	Total (€)
ORT-001	Initial Comprehensive Orthodontic Consultation Includes panoramic radiograph (OPG), cephalometric analysis, and digital intraoral scanning. Assessment of malocclusion severity and discussion of treatment options including fixed appliances and clear aligners.	1	150.00	150.00
ORT-002	Fixed Appliance Therapy (Braces) - Upper Arch Placement of self-ligating ceramic brackets on the maxillary arch. Includes bonding, archwire insertion, and initial adjustment. This procedure is performed in accordance with Belgian orthodontic standards.	1	1,200.00	1,200.00
ORT-003	Fixed Appliance Therapy (Braces) - Lower Arch Placement of self-ligating ceramic brackets on the mandibular arch. Includes bonding, archwire insertion, and initial adjustment.	1	1,200.00	1,200.00
ORT-004	Intermaxillary Elastics and Auxiliaries Supply and placement of elastic bands to correct bite alignment (Class II correction). Includes power chains and coil springs as required during the active treatment phase in Brussels.	1	350.00	350.00
ORT-005	Monthly Adjustment and Monitoring Visit Routine check-up to tighten archwires, replace elastics, and monitor tooth movement. Includes oral hygiene instruction specific to orthodontic appliances.	3	120.00	360.00
ORT-006	Emergency Repair Service Repair of broken bracket on tooth #24. Includes replacement of bracket and re-ligation of archwire.	1	85.00	85.00

Subtotal	€ 3,345.00
VAT (21% - Standard Rate Belgium)	€ 702.45
INAMI/RIZIV Reimbursement Estimate	- € 450.00
Total Amount Due	€ 3,597.45

Payment Instructions

Please transfer the total amount due to our bank account within 30 days of the invoice date.
Bank: KBC Bank Brussels
IBAN: BE68 5390 0754 7032
BIC: KREDBEBB
Reference: INV-2023-10-045

Important Information Regarding Orthodontic Treatment in Belgium

1. INAMI/RIZIV Reimbursement: In Belgium, orthodontic treatment for minors (under 18) may be partially reimbursed by the national health insurance (INAMI/RIZIV) if the malocclusion meets specific severity criteria (Index of Orthodontic Treatment Need - IOTN). The amount listed as "INAMI/RIZIV Reimbursement Estimate" is an approximation based on current tariffs. The patient is responsible for submitting the necessary forms to their mutual insurance fund (Mutualité/ Mutualiteit). Any difference between the estimate and the actual reimbursement is the responsibility of the patient.

2. VAT Regulations: As per Belgian tax law, orthodontic services provided by a specialist orthodontist are subject to the standard VAT rate of 21%. This invoice is compliant with the regulations set by the Federal Public Service Finance in Brussels.

3. Treatment Compliance: Successful orthodontic outcomes depend heavily on patient compliance. This includes maintaining excellent oral hygiene, wearing elastics as prescribed, and avoiding hard or sticky foods that can damage the appliances. Failure to attend scheduled appointments in Brussels may result in delays to treatment and additional costs.

4. Retention Phase: Upon completion of active treatment, a retention phase is mandatory to maintain the new tooth positions. Retainers (fixed or removable) are not included in this invoice and will be billed separately.

5. Contact: For any questions regarding this invoice or your treatment plan, please contact our administrative office in Brussels during business hours (Monday to Friday, 08:30 - 18:00).

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