Invoice Orthodontist in Senegal Dakar –Free Word Template Download with AI
Dr. Aminata Diop, DDS, MS Orthodontics
12 Avenue Cheikh Anta Diop, Sacré-Cœur
Dakar, Senegal
Tel: +221 33 869 12 34 | Email: [email protected]
Reg. No: RM-DKR-2023-8891
Bill ToPatient Name: Moussa Ndiaye
Address: 45 Rue de Thiong, Almadies
City: Dakar, Senegal
Phone: +221 77 456 78 90
Insurance Provider: Sanlam Senegal (Policy #SN-998877)
Description of Orthodontic Services| Item | Description | Date | Unit Price (XOF) | Total (XOF) |
|---|---|---|---|---|
| 1 |
Initial Comprehensive Orthodontic Consultation Includes panoramic radiograph (OPG), cephalometric analysis, and digital intraoral scanning. Assessment of malocclusion severity and discussion of treatment options tailored for the patient's specific dental anatomy. |
Oct 10, 2023 | 45,000 | 45,000 |
| 2 |
Phase 1: Pre-Orthodontic Preparation Scaling and root planing to ensure periodontal health prior to appliance placement. Extraction of supernumerary teeth to create necessary space for alignment. |
Oct 12, 2023 | 120,000 | 120,000 |
| 3 |
Custom Metal Braces System (Full Arch) Supply and bonding of high-grade stainless steel brackets on both maxillary and mandibular arches. Includes archwires, ligatures, and bonding agents. This is the primary appliance for correcting the Class II malocclusion. |
Oct 15, 2023 | 350,000 | 350,000 |
| 4 |
First Month Adjustment & Activation Initial wire placement and activation to begin tooth movement. Patient education on oral hygiene maintenance specific to orthodontic appliances in the Dakar climate. |
Oct 20, 2023 | 30,000 | 30,000 |
| 5 |
Emergency Repair Service Replacement of a debonded bracket on the lower left canine due to accidental trauma. Includes re-bonding and wire adjustment. |
Oct 22, 2023 | 15,000 | 15,000 |
Amount in words: Six Hundred Thirty-Seven Thousand Two Hundred CFA Francs.
Payment Terms & Conditions1. Payment Methods: Payment can be made via bank transfer to our account at Ecobank Senegal (Account: 1234567890), mobile money (Orange Money/Wave), or cash at our clinic in Dakar. Please reference the Invoice Number on all payments.
2. Due Date: The full amount is due within 30 days of the invoice date. Late payments may incur a penalty fee of 5% per month.
3. Insurance: If you are using insurance coverage, please submit this invoice along with the clinical report to your provider. Our office can assist with pre-authorization forms for major orthodontic procedures.
4. Treatment Plan: This invoice covers the initial phase of treatment. Future adjustments and the final retention phase will be billed separately according to the signed treatment agreement.
5. Contact: For any questions regarding this invoice or your orthodontic treatment plan, please contact our billing department at +221 33 869 12 34 or visit us at our clinic in Sacré-Cœur, Dakar.
Authorized Signature
Dr. Aminata Diop
Lead Orthodontist
Patient Acknowledgement
Moussa Ndiaye
Date: _______________
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