Invoice Orthodontist in Canada Montreal –Free Word Template Download with AI
Specialist in Orthodontics and Dentofacial Orthopedics
1234 Rue Sherbrooke Ouest, Suite 500
Montreal, Quebec, Canada H3A 1B7
Phone: (514) 555-0198 | Email: [email protected]
Quebec College of Dentists (O.D.Q.) License #12345
Invoice Number: INV-2024-0876
Date Issued: October 15, 2024
Due Date: November 15, 2024
| Invoice Reference: | Orthodontic Treatment Plan #TP-2024-045 |
| Treatment Period: | January 2024 – December 2025 |
| Plan Type: | Comprehensive Fixed Appliance Therapy |
BILL TO:
Patient Name: Marie-Claire Dubois
Address: 567 Avenue du Parc, Montreal, Quebec, Canada H2W 1Z5
Phone: (514) 555-0234
Email: [email protected]
Date of Birth: March 12, 2008
Insurance Provider: Great-West Life Canada
Policy Number: GWL-987654321
Group Number: GRP-456789
| Description of Orthodontic Services | Code | Qty | Unit Price (CAD) | Total (CAD) |
|---|---|---|---|---|
| Initial Comprehensive Orthodontic Examination and Diagnostic Records (X-rays, photographs, models) | D0720 | 1 | 350.00 | 350.00 |
| Treatment Planning and Consultation for Fixed Appliance Therapy | D8010 | 1 | 200.00 | 200.00 |
| Placement of Comprehensive Fixed Orthodontic Appliances (Braces) – Upper and Lower Arch | D8050 | 1 | 4,500.00 | 4,500.00 |
| Monthly Adjustment and Progress Evaluation Visits (12 visits included) | D8060 | 12 | 150.00 | 1,800.00 |
| Interarch Elastics and Auxiliary Appliances | D8070 | 1 | 300.00 | 300.00 |
| Removal of Fixed Orthodontic Appliances and Bonding of Retainers | D8080 | 1 | 400.00 | 400.00 |
| Custom Fabricated Retainers (Upper and Lower) | D8090 | 2 | 250.00 | 500.00 |
| Emergency Orthodontic Visit (Wire Adjustment) | D8095 | 1 | 100.00 | 100.00 |
| Post-Treatment Records and Final Evaluation | D8099 | 1 | 150.00 | 150.00 |
| Subtotal: | 8,300.00 |
| Quebec Sales Tax (QST) 9.975%: | 827.93 |
| Goods and Services Tax (GST) 5%: | 415.00 |
| Total Amount Due (CAD): | 9,542.93 |
| Amount Paid (Deposit): | (2,000.00) |
| Balance Due: | 7,542.93 |
Payment Terms and Notes:
This invoice is issued by Dr. Jean-Pierre Tremblay, a licensed orthodontist practicing in Montreal, Quebec, Canada. All services rendered comply with the standards set by the Ordre des dentistes du Québec (O.D.Q.).
Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge.
Accepted payment methods include credit card (Visa, MasterCard, Amex), debit card, e-transfer, and certified cheque. For e-transfer, please contact our office for secure payment details.
If you have insurance coverage through a Canadian provider, please submit this invoice along with your treatment receipt to your insurer for reimbursement. Our office can provide a detailed breakdown of services upon request.
Orthodontic treatment is a long-term commitment. Regular attendance at scheduled appointments is essential for successful outcomes. Missed appointments may result in additional fees or delays in treatment.
For any questions regarding this invoice or your orthodontic treatment plan, please contact our billing department at (514) 555-0198 or email [email protected]. We are committed to providing transparent and professional orthodontic care in Montreal, Canada.
Thank you for trusting our practice with your dental health. We look forward to helping you achieve a healthy, confident smile.
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