Invoice Orthodontist in Ivory Coast Abidjan –Free Word Template Download with AI
Cocody Angré, Riviera 3
Abidjan, Ivory Coast
Phone: +225 27 22 48 90 12
Email: [email protected]
RCCM: AB-2018-B-12345
NIF: CI-9876543210
INVOICE
Invoice Number: INV-2023-0892
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Payment Status: Pending
Bill To (Parent/Guardian)
Monsieur Jean-Marc Kouassi
14 Rue des Jardins, Zone 4
Cocody, Abidjan
Ivory Coast
Phone: +225 07 07 88 99 00
Name: Sophie Kouassi
Date of Birth: March 12, 2010
File Reference: PAT-SK-2023-44
Treatment Plan: Comprehensive Fixed Appliance Therapy
| Item # | Service Description | Date | Amount (XOF) |
|---|---|---|---|
| 1 |
Initial Comprehensive Orthodontic Consultation Includes clinical examination, assessment of occlusion, and discussion of treatment options for malocclusion correction. |
01-Oct-2023 | 25,000 |
| 2 |
Diagnostic Records & Imaging Panoramic radiograph (OPG), Lateral Cephalometric X-ray, and intraoral photographs for treatment planning. |
01-Oct-2023 | 45,000 |
| 3 |
Pre-Orthodontic Preparation Professional prophylaxis (scaling and polishing) and application of fluoride varnish prior to bracket bonding. |
15-Oct-2023 | 30,000 |
| 4 |
Fixed Appliance Therapy (Braces) - Initial Placement Bonding of stainless steel brackets on maxillary and mandibular arches, insertion of archwires, and placement of separators. |
15-Oct-2023 | 450,000 |
| 5 |
Orthodontic Adjustment Visit Routine adjustment of archwires, change of elastic ligatures, and assessment of tooth movement progress. |
24-Oct-2023 | 15,000 |
| 6 |
Emergency Repair Service Re-bonding of dislodged bracket on tooth #24 and replacement of broken archwire segment. |
22-Oct-2023 | 20,000 |
Please make payment within 30 days of the invoice date. Payments can be made via bank transfer, mobile money (Orange Money, MTN MoMo), or cash at our clinic in Abidjan.
Bank Transfer Details:
Bank: Ecobank Côte d'Ivoire
Branch: Cocody Riviera
Account Name: Abidjan Elite Orthodontics SARL
Account Number: 0012345678901
SWIFT Code: ECOBCICI
Mobile Money:
Orange Money: +225 07 07 12 34 56
MTN MoMo: +225 05 05 98 76 54
Important Notes & Terms of Service
1. Treatment Continuity: Regular appointments are crucial for the success of orthodontic treatment. Please schedule your next visit before leaving the clinic. Missed appointments may result in additional fees or delays in treatment completion.
2. Payment Plan: For comprehensive orthodontic treatments, we offer flexible payment plans. Please contact our administrative office to discuss installment options tailored to your financial situation.
3. Emergency Care: In case of orthodontic emergencies (e.g., broken brackets, poking wires), please contact our clinic immediately. We prioritize emergency cases for patients currently undergoing treatment.
4. Retention Phase: Upon completion of active treatment, retainers will be provided to maintain the new position of your teeth. Retainer fees are not included in this invoice and will be billed separately.
5. Validity: This invoice is valid for 30 days from the date of issue. Late payments may incur a penalty fee of 5% per month on the outstanding balance.
6. Disputes: If you have any questions or disputes regarding this invoice, please contact our billing department within 15 days of receipt.
Thank you for choosing Abidjan Elite Orthodontics for your dental care needs. We are committed to providing high-quality orthodontic services in Ivory Coast.
Authorized By Dr. Amina KonéLead Orthodontist Received By Patient/Guardian Signature
Date: _______________
Abidjan Elite Orthodontics | Cocody, Abidjan, Ivory Coast | +225 27 22 48 90 12 | www.abidjanortho.ci
This is a computer-generated invoice. No signature is required for processing.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT