Invoice Orthodontist in South Africa Cape Town –Free Word Template Download with AI
Dr. Sarah van der Merwe, BChD Ortho
123 Kloof Street, Gardens
Cape Town, Western Cape, 8001
South Africa
Tel: +27 (0)21 555 0199
Email: [email protected]
HPCSA Registration: 20240899122
Invoice Number: INV-CT-2023-0892
Date Issued: 24 October 2023
Due Date: 24 November 2023
Reference: Patient ID #88291
Bill To:
Mr. James & Mrs. Linda Thorne
45 Buitengracht Street
De Waterkant, Cape Town
Western Cape, 8001
South Africa
Policy Holder: Mr. James Thorne
Medical Aid: Discovery Health
Policy Number: DIS-99283746
Payment Details:
Please make payment via EFT to the following bank account:
Bank: First National Bank (FNB)
Branch: Cape Town City Centre
Account Name: Cape Town Orthodontic Specialists
Account Number: 6204 9988 7766
Branch Code: 250655
Reference: INV-CT-2023-0892
| Description of Orthodontic Services | SA Code | Quantity | Unit Price (ZAR) | Total (ZAR) |
|---|---|---|---|---|
|
Initial Comprehensive Orthodontic Consultation Including panoramic radiograph, cephalometric analysis, and study models. Assessment of malocclusion and treatment planning for fixed appliance therapy. |
1001 | 1 | 1,200.00 | 1,200.00 |
|
Placement of Fixed Orthodontic Appliances (Braces) Full mouth bonding of stainless steel brackets to upper and lower arches. Includes archwire insertion and ligation. Standard comprehensive treatment initiation. |
1015 | 1 | 18,500.00 | 18,500.00 |
|
Orthodontic Adjustment and Progress Review Monthly adjustment appointment. Includes wire change, elastic placement, and monitoring of tooth movement. Ensures alignment is progressing according to the treatment plan. |
1020 | 4 | 1,500.00 | 6,000.00 |
|
Intermaxillary Elastics (Rubber Bands) Supply of prescription elastics for bite correction and occlusal adjustment. Patient to replace daily as instructed by the orthodontist. |
1055 | 2 | 350.00 | 700.00 |
|
Emergency Orthodontic Repair Repair of loose bracket on lower left canine. Re-bonding and re-ligation to maintain treatment continuity. |
1030 | 1 | 850.00 | 850.00 |
|
Retention Phase: Fixed Retainer Bonding Bonding of permanent fixed retainer wire to lower anterior teeth to prevent relapse of alignment post-treatment. |
1040 | 1 | 2,200.00 | 2,200.00 |
Terms and Conditions & Important Information
This invoice is issued by Cape Town Orthodontic Specialists, a registered practice in South Africa. All services rendered are in accordance with the guidelines set by the South African Orthodontic Society (SAOS).
Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a monthly interest charge of 2% in accordance with the National Credit Act of South Africa.
Medical Aid Claims: We have submitted the relevant claims to Discovery Health on your behalf. The amount deducted above represents the estimated benefit. Please note that final approval is subject to your specific medical aid plan limits and exclusions. Any difference between the estimated and actual benefit will be adjusted in your next statement.
Treatment Plan: This invoice covers the initial phase and ongoing adjustments of your comprehensive orthodontic treatment. Regular attendance at monthly adjustment appointments is crucial for the success of the treatment. Failure to attend appointments may result in extended treatment time and additional costs.
Retention: Following the removal of braces, retention is mandatory to maintain the new position of your teeth. Failure to wear retainers as prescribed may result in relapse, for which no further treatment guarantee is provided.
Contact Us: If you have any questions regarding this invoice or your treatment plan, please contact our billing department at [email protected] or call +27 (0)21 555 0199. We are located in the heart of Cape Town and are committed to providing you with the highest standard of orthodontic care.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT