Invoice Orthodontist in Brazil São Paulo –Free Word Template Download with AI
Specialized Orthodontic Clinic
Av. Paulista, 1578 - 12th Floor, Suite 1205
Bela Vista, São Paulo - SP, Brazil
CEP: 01310-200
Phone: +55 (11) 3254-8900
Email: [email protected]
CNPJ: 12.345.678/0001-90
CRM-SP: 123456 | CRO-SP: 78901
Invoice Number: INV-2024-0892
Date Issued: January 15, 2024
Due Date: February 15, 2024
Payment Terms: Net 30 Days
Service Period: January 2024
Bill To:
Patient Name: Maria Fernanda Silva Santos
CPF: 123.456.789-00
Address: Rua Oscar Freire, 450 - Apt 82
Jardins, São Paulo - SP, Brazil
CEP: 01426-001
Phone: +55 (11) 98765-4321
Email: [email protected]
Insurance Provider: Amil Saúde
Policy Number: AM-987654321
Orthodontic Services Rendered
This invoice details the professional orthodontic services provided by Dr. Ricardo Mendes, a certified orthodontist practicing in São Paulo, Brazil. All procedures comply with the standards established by the Brazilian Federal Council of Dentistry (CFO) and the São Paulo Regional Council of Dentistry (CRO-SP).
| Item # | Description of Service | Procedure Code (CBO) | Date of Service | Quantity | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|---|
| 1 | Initial Orthodontic Consultation and Diagnostic Evaluation | 2251-05 | 2024-01-05 | 1 | R$ 350.00 | R$ 350.00 |
| 2 | Comprehensive Cephalometric and Panoramic Radiographic Analysis | 2251-13 | 2024-01-05 | 1 | R$ 480.00 | R$ 480.00 |
| 3 | Dental Impressions and Digital Scan for Treatment Planning | 2251-21 | 2024-01-05 | 1 | R$ 275.00 | R$ 275.00 |
| 4 | Custom Orthodontic Treatment Plan Development | 2251-30 | 2024-01-08 | 1 | R$ 600.00 | R$ 600.00 |
| 5 | Placement of Fixed Metal Braces (Full Arch - Upper and Lower) | 2252-10 | 2024-01-12 | 1 | R$ 4,500.00 | R$ 4,500.00 |
| 6 | Archwire Adjustment and Activation (First Month) | 2252-28 | 2024-01-12 | 1 | R$ 350.00 | R$ 350.00 |
| 7 | Orthodontic Elastics and Accessories Supply | 2252-45 | 2024-01-12 | 1 | R$ 150.00 | R$ 150.00 |
| 8 | Patient Education on Oral Hygiene with Braces | 2252-53 | 2024-01-12 | 1 | R$ 100.00 | R$ 100.00 |
| Subtotal: | R$ 6,805.00 |
| Discount (Insurance Coverage): | - R$ 2,300.00 |
| SS Contribution (INSS - 9.5%): | R$ 426.48 |
| Income Tax (IRRF - 7.5%): | R$ 340.25 |
| Total Due: | R$ 5,231.73 |
Important Notes and Payment Instructions:
Payment Methods Accepted: Bank Transfer (TED/DOC), PIX (Instant Payment), Credit Card (up to 6 installments), or Cash.
Bank Details for Transfer:
Bank: Banco do Brasil
Agency: 1234-5
Account: 98765-4
Account Holder: Ricardo Mendes Orthodontics Ltda.
PIX Key: [email protected]
Late Payment: A late fee of 2% per month plus interest of 1% per month will be applied to overdue invoices, in accordance with Brazilian consumer law.
Insurance Claims: This invoice has been submitted to Amil Saúde for partial coverage. The patient is responsible for the remaining balance as indicated above.
Follow-up Appointments: Your next orthodontic adjustment appointment is scheduled for February 12, 2024, at 10:00 AM. Please arrive 15 minutes early.
Emergency Contact: In case of orthodontic emergencies (broken brackets, wires, etc.), please contact our São Paulo clinic immediately at +55 (11) 3254-8900.
Legal Compliance: This invoice complies with Brazilian tax regulations and the professional standards set by the Conselho Regional de Odontologia de São Paulo (CRO-SP). All services were performed in accordance with the Código de Ética Odontológica.
Authorized by:
Dr. Ricardo Mendes
Orthodontist - CRO-SP: 78901
Date: January 15, 2024
Patient Acknowledgment:
Maria Fernanda Silva Santos
CPF: 123.456.789-00
Date: _______________
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