Invoice Orthodontist in Sudan Khartoum –Free Word Template Download with AI
Dr. Ahmed El-Tayeb, DDS, MS Orthodontics
Al-Amiriya Street, Block 4, Building 12
Khartoum, Sudan
Tel: +249 183 123 456
Email: [email protected]
Tax ID: SD-ORTHO-998877
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Payment Status: Pending
Bill To:
Patient Name: Sarah Mohamed Hassan
Address: Al-Riyadh District, Street 5, House 22
Khartoum North, Sudan
Phone: +249 912 345 678
Patient ID: PAT-8842
Insurance / Guarantor Details:
Provider: Sudan National Health Insurance
Policy Number: SNHI-2023-5544
Group ID: GOV-EMP-001
Authorization Code: AUTH-9921
| # | Description of Orthodontic Services | Code | Qty | Unit Price (SDG) | Total (SDG) |
|---|---|---|---|---|---|
| 1 |
Initial Comprehensive Orthodontic Consultation Detailed clinical examination of the patient's dentition and facial structure. This includes the assessment of occlusion, jaw alignment, and periodontal health. Discussion of treatment options available at our Khartoum clinic, including traditional braces and clear aligner therapy. |
D0680 | 1 | 15,000.00 | 15,000.00 |
| 2 |
Diagnostic Imaging and Records Full series of panoramic radiographs (OPG) and lateral cephalometric X-rays. These images are crucial for the orthodontist to analyze bone structure and tooth positioning. Includes digital impressions for 3D treatment planning. |
D0330 | 1 | 25,000.00 | 25,000.00 |
| 3 |
Fixed Appliance Therapy (Metal Braces) - Upper Arch Placement of high-quality stainless steel brackets and archwires on the maxillary arch. This procedure involves bonding brackets to the teeth and securing the initial archwire to begin the alignment process. Includes all necessary ligatures and bands. |
D8050 | 1 | 120,000.00 | 120,000.00 |
| 4 |
Fixed Appliance Therapy (Metal Braces) - Lower Arch Placement of stainless steel brackets and archwires on the mandibular arch. This completes the full fixed appliance setup required for comprehensive orthodontic correction in Sudan. |
D8050 | 1 | 120,000.00 | 120,000.00 |
| 5 |
Intermaxillary Elastics and Auxiliary Appliances Provision of rubber bands (elastics) to correct bite discrepancies (overbite/underbite). Includes instructions on usage and replacement schedule. |
D8060 | 1 | 10,000.00 | 10,000.00 |
| 6 |
First Month Adjustment and Follow-up Routine adjustment appointment to tighten archwires and monitor tooth movement. Evaluation of patient compliance with elastics and oral hygiene instructions. |
D8060 | 1 | 5,000.00 | 5,000.00 |
Terms and Conditions & Important Notes
This invoice represents the charges for orthodontic services rendered at Khartoum Elite Orthodontics. The total amount is due within 14 days of the invoice date. Please note that all prices are listed in Sudanese Pounds (SDG).
Payment Methods: We accept cash, bank transfer to Bank of Khartoum (Account: 1234567890), and mobile money via ZainCash or MTN Mobile Money. For bank transfers, please include the Invoice Number as the reference.
Treatment Plan: Orthodontic treatment is a long-term commitment. This invoice covers the initial phase of treatment. Future adjustments and retention appliances will be billed separately according to the agreed-upon treatment plan. Regular attendance at appointments is crucial for the success of the orthodontic treatment.
Missed Appointments: Please notify our clinic at least 24 hours in advance if you need to reschedule. A fee of 5,000 SDG may be charged for missed appointments without notice.
Oral Hygiene: Patients undergoing orthodontic treatment must maintain excellent oral hygiene to prevent decalcification and gum disease. Our orthodontist in Khartoum recommends brushing after every meal and using interdental brushes.
Emergency Care: In case of bracket breakage or wire irritation, please contact our clinic immediately. Emergency appointments are available for urgent orthodontic issues.
Thank you for choosing Khartoum Elite Orthodontics for your dental care needs. We are committed to providing the highest standard of orthodontic treatment in Sudan.
Authorized by:
Dr. Ahmed El-Tayeb
Lead Orthodontist
Khartoum Elite Orthodontics
Patient/Guarantor Signature:
Date: _______________
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