Invoice Orthodontist in Netherlands Amsterdam –Free Word Template Download with AI
Dr. J. van der Berg, Specialist Orthodontist
Keizersgracht 123
1015 CJ Amsterdam, Netherlands
KVK: 34567890 | BTW: NL856789012B01
Tel: +31 20 123 4567
Email: [email protected]
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Reference: Treatment Plan Phase II
Bill To (Policy Holder)
Mr. Robert de Vries
Herengracht 456
1017 CA Amsterdam, Netherlands
Insurance: Zilveren Kruis (Policy #ZK-998877)
Patient Details
Ms. Sophie de Vries
Date of Birth: 12-05-2010
BSN: 123456789
Treatment Type: Comprehensive Orthodontic Correction
| # | Description of Orthodontic Services | Date of Service | Quantity | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|---|
| 1 |
Initial Diagnostic Consultation & Imaging Comprehensive clinical examination, panoramic X-ray (OPG), and cephalometric analysis required for treatment planning in accordance with Dutch orthodontic standards. |
01-09-2023 | 1 | 150.00 | 150.00 |
| 2 |
Fixed Appliance Therapy (Brackets & Bands) Placement of self-ligating ceramic brackets on upper and lower arches. Includes bonding, adjustment, and initial archwire insertion. |
15-09-2023 | 1 | 2,400.00 | 2,400.00 |
| 3 |
Monthly Adjustment Visit Routine orthodontic adjustment, wire change, and progress monitoring. Essential for maintaining treatment velocity and alignment accuracy. |
20-10-2023 | 1 | 125.00 | 125.00 |
| 4 |
Intermaxillary Elastics & Auxiliaries Supply of elastic bands and power chains to correct bite discrepancy (Class II malocclusion). |
20-10-2023 | 1 | 45.00 | 45.00 |
| 5 |
Emergency Repair Service Re-bonding of dislodged molar band on the lower right quadrant due to trauma. |
10-10-2023 | 1 | 75.00 | 75.00 |
Payment Instructions
Please transfer the outstanding balance to the following bank account within 30 days of the invoice date:
Bank: ING Bank N.V., Amsterdam
Account Name: Amsterdam Orthodontic Center B.V.
IBAN: NL91 INGB 0001 2345 67
BIC/SWIFT: INGBNL2A
Reference: INV-2023-10-045 / Sophie de Vries
Note: Late payments may incur a statutory interest rate as per Dutch Civil Code (Burgerlijk Wetboek).
Terms and Conditions
This invoice represents the financial agreement between the patient/insurer and the Orthodontist located in Amsterdam, Netherlands. All prices are inclusive of the standard Dutch Value Added Tax (BTW) of 21%. The services rendered are based on the current treatment plan approved by the specialist orthodontist.
In accordance with the regulations of the Dutch Health Care Inspectorate (IGZ), this document serves as a formal record of medical billing. The patient is responsible for any costs not covered by their supplementary dental insurance (tandverzekering). If the insurance company requires additional documentation, such as a detailed treatment plan or medical necessity letter, please contact our administrative office in Amsterdam immediately.
Payment is due within 30 days. If payment is not received by the due date, a reminder will be issued. Persistent non-payment may result in the suspension of orthodontic treatment until the account is settled. This invoice is valid for tax purposes in the Netherlands. Please retain this document for your personal records and insurance claims.
For any questions regarding this invoice, please contact our billing department at +31 20 123 4567 or via email at [email protected]. We appreciate your prompt attention to this matter and thank you for choosing Amsterdam Orthodontic Center for your dental health needs.
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