Invoice Orthodontist in Chile Santiago –Free Word Template Download with AI
Specialized Dental Care & Smile Correction
Av. Providencia 1234, Office 501
Providencia, Santiago, Chile
RUT: 76.543.210-K
Phone: +56 2 2345 6789
Email: [email protected]
Bill To (Patient)Mr. Alejandro Gonzalez Silva
RUT: 15.678.901-2
Los Leones 450, Dept 12B
Las Condes, Santiago, Chile
Email: [email protected]
Phone: +56 9 8765 4321
Insurance / Third PartyIsapre Cruz Blanca
Policy Number: CB-99887766
Authorization Code: AUTH-2023-XY
Reference: Orthodontic Treatment Plan Phase 1
Description of Orthodontic ServicesThe following invoice details the professional fees for orthodontic consultation, diagnostic imaging, and the initiation of corrective dental treatment provided at our Santiago clinic. All procedures adhere to the standards set by the Chilean Society of Orthodontics and local health regulations.
| # | Service Description | Qty | Unit Price (CLP) | Total (CLP) |
|---|---|---|---|---|
| 1 |
Initial Orthodontic Consultation & Diagnosis Comprehensive evaluation of dental alignment, occlusion analysis, and discussion of treatment options including traditional braces and clear aligners. Includes review of medical history specific to dental development. |
1 | $45.000 | $45.000 |
| 2 |
Diagnostic Imaging Suite Panoramic X-ray (OPG) and Lateral Cephalometric Radiograph. Essential for assessing bone structure, root position, and growth patterns in the Santiago patient demographic. Digital processing included. |
1 | $65.000 | $65.000 |
| 3 |
Intraoral Impressions & 3D Scanning Creation of precise physical molds and digital 3D models of the upper and lower arches. Used for treatment simulation and appliance fabrication. |
1 | $55.000 | $55.000 |
| 4 |
Pre-Orthodontic Dental Hygiene Professional prophylaxis and scaling to ensure optimal oral health prior to the placement of orthodontic appliances. Reduces risk of gingivitis during treatment. |
1 | $40.000 | $40.000 |
| 5 |
Placement of Fixed Orthodontic Appliances (Metal Braces) Bonding of brackets and archwires to both arches. Includes initial adjustment and patient education on care and hygiene maintenance in the Santiago metropolitan area. |
1 | $450.000 | $450.000 |
| 6 |
Orthodontic Elastics & Accessories Kit Provision of initial set of intermaxillary elastics, wax for irritation prevention, and specialized toothbrushes recommended for patients undergoing orthodontic treatment. |
1 | $25.000 | $25.000 |
| 7 |
First Month Adjustment Visit Follow-up appointment to monitor initial tooth movement, adjust wire tension, and ensure patient comfort. |
1 | $35.000 | $35.000 |
Payments can be made via bank transfer, credit card, or cash at our Santiago office.
- Bank Transfer: Banco Estado, Account: 123456789-0, RUT: 76.543.210-K
- Credit Card: Visa, Mastercard, American Express accepted in-office.
- Reference: Please use Invoice Number INV-2023-0892 as the payment reference.
1. Payment is due within 14 days of the invoice date. Late payments may incur a penalty fee of 2% per month.
2. This invoice covers the initial phase of orthodontic treatment. Subsequent monthly adjustment visits will be billed separately or according to the pre-agreed treatment plan.
3. Santiago Advanced Orthodontics reserves the right to pause treatment if payments are overdue by more than 30 days.
4. All prices are quoted in Chilean Pesos (CLP) and include applicable taxes as per Chilean law.
5. Please retain this invoice for your records and for any insurance reimbursement claims.
Santiago Advanced Orthodontics is a registered healthcare provider in Chile, operating under the supervision of the Superintendencia de Salud. Our orthodontic services are performed by licensed specialists certified by the Colegio de Cirujanos Dentistas de Chile. This document serves as a formal request for payment for professional services rendered. By accepting our treatment, the patient agrees to the terms outlined in the initial consent form and this invoice. Any disputes regarding billing should be addressed directly with our administrative office in Santiago within 10 business days of receipt. We are committed to providing transparent and high-quality orthodontic care to our community in Santiago and the surrounding regions.
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