Invoice Orthodontist in DR Congo Kinshasa –Free Word Template Download with AI
Dr. Jean-Pierre Mbemba, DDS, MS Orthodontics
Av. de la Paix, N° 145, Gombe
Kinshasa, Democratic Republic of Congo
Tel: +243 81 234 5678 | Email: [email protected]
NIF: 001234567890123 | RCCM: CD-KIN-2015-00123
Bill To:
Monsieur Antoine Kabila
Résidence Les Palmiers, Quartier Ngaliema
Kinshasa, Democratic Republic of Congo
Phone: +243 99 876 5432
Email: [email protected]
Patient Information:
Patient Name: Marie Kabila
Date of Birth: March 12, 2010
Insurance Provider: Mutuelle Santé Congo
Policy Number: MSC-2024-78901
Treatment Plan ID: TP-2024-0456
| # | Description of Orthodontic Services | Qty | Unit Price (CDF) | Total (CDF) |
|---|---|---|---|---|
| 1 |
Initial Comprehensive Orthodontic Consultation Includes panoramic X-ray, cephalometric analysis, intraoral photographs, and treatment planning session conducted at our Kinshasa clinic. |
1 | 250,000 | 250,000 |
| 2 |
Fixed Appliance System (Metal Brackets) - Full Arch Premium stainless steel brackets with archwires for both upper and lower dental arches. Includes bonding procedure and initial adjustment. |
1 | 3,500,000 | 3,500,000 |
| 3 |
Monthly Adjustment and Monitoring Visit Regular orthodontic adjustment appointment including wire changes, ligature replacement, and progress evaluation. Billed for October 2024. |
1 | 150,000 | 150,000 |
| 4 |
Intermaxillary Elastics (Rubber Bands) Supply of orthodontic elastics for bite correction. Monthly refill package. |
1 | 50,000 | 50,000 |
| 5 |
Emergency Orthodontic Repair Urgent repair of broken bracket on upper right canine. Includes replacement bracket and rebonding procedure. |
1 | 100,000 | 100,000 |
| 6 |
Progress Radiographic Examination Digital panoramic X-ray to monitor root movement and treatment progress at 6-month interval. |
1 | 120,000 | 120,000 |
| 7 |
Orthodontic Retainer Fabrication (Hawley Type) Custom-made removable retainer for upper arch. Includes impressions, laboratory fees, and fitting appointment. |
1 | 350,000 | 350,000 |
| 8 |
Professional Dental Cleaning (Prophylaxis) Comprehensive cleaning around orthodontic appliances to prevent gingivitis and ensure optimal oral health during treatment. |
1 | 80,000 | 80,000 |
| Subtotal: | 4,600,000 CDF |
| Insurance Coverage (Mutuelle Santé Congo): | -1,500,000 CDF |
| Discount (Loyalty Patient): | -100,000 CDF |
| Net Amount: | 3,000,000 CDF |
| VAT (16% - DR Congo Tax Law): | 480,000 CDF |
| TOTAL DUE: | 3,480,000 CDF |
Amount in Words: Three Million Four Hundred Eighty Thousand Congolese Francs (CDF)
Payment Instructions:
Please remit payment within 15 days of the invoice date to avoid late fees. Payment can be made through the following methods:
Bank Transfer:
Bank: Banque Commerciale du Congo (BCC)
Branch: Gombe, Kinshasa
Account Name: Kinshasa Orthodontic Center SARL
Account Number: 001234567890123456
SWIFT/BIC: BCCDCDKX
Mobile Money:
Airtel Money: +243 81 234 5678
M-Pesa: +243 99 876 5432
Cash Payment:
Accepted at our clinic during business hours (Monday-Friday: 8:00 AM - 5:00 PM, Saturday: 8:00 AM - 12:00 PM).
Terms and Conditions:
1. This invoice is issued in accordance with the tax regulations of the Democratic Republic of Congo. All prices are quoted in Congolese Francs (CDF).
2. Late payments will incur a penalty of 2% per month on the outstanding balance after the due date.
3. Insurance claims are processed directly with Mutuelle Santé Congo. The patient is responsible for any co-payments or non-covered services as indicated on this invoice.
4. Orthodontic treatment requires regular attendance at scheduled appointments. Missed appointments may result in additional charges or treatment delays.
5. This invoice serves as an official receipt upon full payment. Please retain this document for your records and insurance purposes.
6. For any questions regarding this invoice or your orthodontic treatment plan, please contact our billing department at +243 81 234 5678 or email [email protected].
7. All orthodontic services are provided by licensed professionals registered with the Ordre National des Médecins Dentistes de la République Démocratique du Congo.
Authorized Signature:
Dr. Jean-Pierre Mbemba
Lead Orthodontist
Kinshasa Orthodontic Center
Patient/Guardian Acknowledgment:
_________________________
Name & Signature
Date: _________________
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